THE WORK OF WHO 1978-!979

Biennial Report of the Director-General to the World Health Assemb!J and to the United Nations

WORLD HEALTH ORGANIZATION GENEVA

Contents

Page Declaration of Alma-Ata VII

Introduction...... XI

I. Policy basis :World Health Assembly, Executive Board and regional committees I

Strategies for health for all by the year 2000 . • Programme Committee of the Executive Board . 2 Organizational studies of the Executive Board Technical Discussions . . . . . 5 Programme trends and priorities 6 Health and peace ...... 9

z. General programme development and management II

National health programme development II WHO's programme development process I7

3. Coordination ...... Nongovernmental organizations Extrabudgetary sources of funds United Nations Children's Fund United Nations Development Programme World Food Programme .. United Nations volunteers ...... Collaboration with China ...... Technical cooperation among developing countries Emergency relief operations ......

4· Research promotion and development ' . Global developments . Regional developments

5. Health services development 4Z

Primary health care ...... 43 Appropriate technology for health . 45 Disability prevention, rehabilitation, and health care of the elderly. 46

III Page

Health services planning and management Health services research Traditional medicine Workers' health .

6. Family health . 59 Maternal and child health Nutrition ...... Health education Special Programme of Research, Development and Research Training in Human Reproduction

7· Mental health ...... Community health services and health manpower . Training ...... Biomedical and health practice research . . . . . Mechanisms for programme development and support

8. Prophylactic, diagnostic and therapeutic substances. 88 Drug policies and management . 88 Pharmaceuticals ...... 91 Biologicals ...... 93 Health laboratory technology. 95

9· Communicable disease prevention and control 98 Epidemiological surveillance . . 98 Safety measures in microbiology 99 Smallpox eradication . 99 Malaria ...... 101 Other parasitic diseases . . 105 Bacterial and viral diseases . Ill Diarrhoeal diseases . . . 120 Prevention of blindness . . 121 Veterinary public health . . 122 Vector biology and control 125 Expanded Programme on Immunization . 129 Special Programme for Research and Training in Tropical Diseases I3J

Io. Noncommunicable disease prevention and control . Cancer ...... International Agency for Research on Cancer Cardiovascular diseases ...... Other chronic noncommunicable diseases Oral health . . . Radiation medicine Human genetics Immunology

I I. Promotion of environmental health Programme development ...... Provision of basic sanitary measures Control of environmental pollution and hazards Food safety ......

IV

Declaration of Alma-Ata

The following is the text of the Declaration of Alma-Ata, issue of the International Conference on Primary Health Care, I978, and endorsed 1(y the Thirry-second World Health Assemb!J and United Nations General Assemb!J at its thirry­ Jourth session.

The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration :

I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.

III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed coun­ tries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.

VII THE WORK OF WHO, 1978-1979

IV

The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

v Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year zooo of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of develop­ ment in the spirit of social justice.

VI

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to indi­ viduals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their develop­ ment in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

VII

Primary health care :

1. reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience ;

2.. addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly ; 3· includes at least: education concerning prevailing health problems and the methods of preventing and controlling them ; promotion of food supply and proper nutrition ; an adequate supply of safe water and basic sanitation ; maternal and child health care, including family planning ; immunization against the major infectious diseases ; prevention and control of locally endemic diseases ; appropriate treatment of common diseases and injuries ; and provision of essential drugs ;

VIII DECLARATION OF ALMA-ALTA

4· involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors ; 5. requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources ; and to this end develops through appropriate education the ability of communities to participate ; 6. should be sustained by integrated, functional and mutually-supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need ; 7. relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.

VIII All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country's resources and to use available external resources rationally.

IX All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world.

X An acceptable level of health for all the people of the world by the year zooo can be attained through a fuller and better use of the world's resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, detente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the accel­ eration of social and economic development of which primary health care, as an essential part, should be allotted its proper share. * * * The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health

IX THE WORK OF WHO, 1978-1979 care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, non-governmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing apd main­ taining primary health care in accordance with the spirit and content of this Declaration.

X Introduction

I978 and I979 will go down in health history as the years dominated 0 two momentous declarations-the one embot!Jing an aspiration, the other heralding the triumph of an aspiration. The first is the Declaration of Alma-Ata; the second is the Declaration of the Global Eradi­ cation of Smallpox. The Declaration of Alma-Ata has been called the twentieth century Magna Carta for health. Its technical content, its demand for social justice in health matters, and its plea for urgent national and international action for health may not be startlinglY new. But taken together in the worldwide political and social context in which thry crystallized thry manifest an unusual degree of international consensus on the need for cooperation among countries, among different social and economic sectors within those countries, and among different interests and disciplines within the health sector to attain an acceptable level of health for all the people of the world. The Declaration of Alma-Ata expressed the stirrings of an international health conscience; but more than that it marked the beginning of an international health movement whose aspiration is health fur all 0 the year 2000. The Declaration, however, did not mere!J formulate a mes­ sianic dream : it gave very clear indications as to its realization.

In I979 the Executive Board of the World Health Organization responded to the plea for urgent action. It prepared guiding principles for formulating national policies, strategies, and plans of action based on primary health care, conceived as part of a comprehensive health .rystem and carried out in coordination with other sectors of socioecouomic development. The Thirry-second World Health Assemb!J adopted those principles and recommended to Member States that thry use them forthwith. Matry countries have alreat!J embarked on their new health strategies, and WHO's regional committees at their I979 sessions agreed to develop regional strategies in support of national efforts. So the International Conference on Primary Health Care which issued the Declaration of Alma-Ata and the aftermath of that Conference are like!J to change the course of worldwide efforts for health, and not least the efforts ~( WHO as the directing and coordinating authority on international health work, fulfilled through the co­ operation of its IJ2 Member States. This tJJanifestation of international cooperation stands in refreshing contrast to many other areas of international concern. I am thinking in partimlar of the New International Economic Order, whose establishment seems to be attended more 0 confrontation than 0 cooperation. Yet I remain convinced that recent events in national and international health work, with their emphasis on multisectoral action for human development, could help to establish that New Inter-

XI THE WORK OF WHO, 1978-1979

national Economic Order if on!J the politicians and economic planners would capitalize on the good will to cooperate in social and economic development that is being generated dai!J.

To ensure interest, guidance and support for the international movement for health on the part of other development sectors as well as the health sector, consultations are taking place with eminent experts in these fields. Also, in fttll accord with the principles of the New International Economic Order, a Healthj2ooo Resources Group is being established to facilitate the rational­ ization of the flow of international resources for health so that priority is given to the strategies that will ensure health for all the developing countries.

The I979 resolution of the United Nations General Assemb!J (J4/J8) that recognized health as an integral part of development is a source of great encouragement. It endorsed the Declaration of Alma-Ala, appealed to Member States to carry out the action called for in that Declaration, welcomed the priority allocation of WHO's resources to the achievement of health for all 1ry the year 2ooo, and ef!ioined the international community to give full support to those efforts. There are many issues on which the resolutions adopted are on!J too often mere statements of aspirations whose realization requires complex and time-consuming negotiations between countries, but in the case of its resolution on health and development, the General Assemb!J can rest assured that the implementation has alreatfy begun with a remarkable degree of agreement among those who voted for it.

National and international determination were among the kry factors in the success of the smallpox eradication. The Declaration of Smallpox Eradication will be formal!J made at the Thirty-third World Health Assemb!J in Ig8o. But it was made de facto in December I979 when the Global Commission for the Certification of Smallpox Eradication announced that, two years having elapsed since the detection in Somalia of the last case of endemic smallpox, the world was now smallpox-free. Other factors that contributed to success were the dedication of the national and international staff working on the campaign, and the high degree to which people in the countries concerned took an interest in ridding themselves of the disease and eager!J took part in efforts for its elimination.

Important lessons can be learned from smallpox eradication-but the idea that we should single out other diseases for worldwide eradication campaigns is not among them. That idea is tempting but illusory. The epidemiology of smallpox is unlike that of atry other disease, and its control and subsequent eradication were based on the wise use of epidemiological knowledge. Skilful scientific and technological research preceded the development of a freeze-dried vaccine and of the bifurcated needle to administer it. Local epidemiological investigations, health services and social research were deplqyed to ensure that the strategy of containment, surveillance, and selective vaccination in endemic areas was both efjicient and effective.

Now that it is possible to discontinue mass vaccination as a routine measure, the affluent countries will save some I200 million US dollars a year. Here is a costfbenefit success story if ever there was one ! But the success story will have a punch-line on!J if the governments of these countries decide to plough back the monry thry have saved into other activities for attaining world health. There is no lack of objects of useful expenditure. But we must all realize that wise investment in health requires a proper assessment of the situation; research and development to find not on!J the appropriate and feasible technologies and delivery .rystems but also a range of social and economic measures; and the determined application of whatever blend of measures is

XII INTRODUCTION

adopted. This approach was successful in the case of smallpox and is accepted practice in other fields of endeavour. It is also a central theme of primary health care as defined at the Conference in Alma-Ata. It must now become the mle rather than exceptiolt i1t the field of health.

That WHO has been trying during the past two years to follow the above advice JJICf)' not emerge clear!J enough from the detailed report that follmvs. But it has bem trying hard. The research and development aspects of its programme have evolved rapid!J in both scope and content. The network of scientists throughout the world who are working 1vithin WHO's coordinating mech­ anisms has steadi!J enlarged. In every WHO region an advisory committee on medical research has been active in determini1tg regional health research priorities based on countries' health needs. One example of worldwide collaboration in health research can be given. Since diarrhoea is a major public health scourge particularlY in developi11g countries, research on its control is now being tackled as a collaborative effort of all these regional advisory committees and of the global Advisory Committee on Medical Research. I hope that, in their scientific excitement, the col­ laborating investigators do not lose sight of the economic, social a11d environmental factors, and that thry do not forget the famous "Broad Street pump approach", which ~ identifying-and removing-the mechanism of transmission of cholera in an outbreak in London near!J I JO years ago, succeeded in interrupting the epidemic in spite of the absence of scientific knowledge as to the precise nature of the disease. The need to take account of such factors has become increasing!J evident to those involved in the Special Programmes for Research and Training in Tropical Diseases and for Research, Development and Research Training in Human Reproduction. The understanding of the im­ portance of building up research capacities in developing countries as an essential step towards their ultimate self-reliance in health matters emerges clear!J from the annual report for I!J7!J of these two Programmes, whose goals are high!J relevant to the social and economic future of mankind, not to speak of the wellbeing of people. These reports make rewarding reading. Thry vibrate with scientific tension, carejui!J thought-out content, and probings for a speetfy application of research findings. Even if immediate results in the form of breakthroughs have not yet been forthcoming, the long-term value is alreatfy apparent of involving a wide community of scientists from whatever disciplines appear necessary and also health managers, from both developing and developed countries. If similar satisfaction cannot be expressed with research in nutrition, nevertheless a major step forward in this area was taken ~ the successful meeting on infant and young child feeding in I!J7!J· This meeting can be regarded as a milestone event, in that representatives ofgovernments, United Nations agencies, nongovernmental organizations, experts in various disciplines, and the infant-food industry met together as equal participants. In spite of the diverse interests thry represented, thry did reach agreement, making practical recommendations for the promotion of breastjeeding. The meeting thus vindicated the poliry of dialogue, leading to the triumph of reason. As requested ~ the meeting, work has alreatfy started on the formulation of an inter­ national code of marketing infant formulas and other products used as breastmilk substitutes. This meeting was organizedjoint!J ~ WHO and UNICEF. It is a pleasure to recall that the two organizations, particularlY since working together for the International Conference on Primary Health Care, have found a common language in matry other areas, for example in joint national and regional activities for the development of strategies for health for all. This wcry of working together on specific matters of common interest is to my mind the best form of collaboration within the United Nations rystem.

XIII THE WORK OF WHO, 1978-1979

WHO's complex relationships with the pharmace11tical industry found their expression in the Organization's endeavours to ensure the availability of essential drugs to people everywhere. When the Thirry-first World Health Assemb!J la11nched the action programme on essential drugs, in Mcry I9J8, it was alreac!J recognized that the existence of an agreed short international list of essential drttgs, and action l!J governments to establish national lists according!J, would not in themselves bring drugs to the people 1vho needed them. It has ?tow become even clearer that these activities have to be accompanied l!J political, industrial, commercial, educational, legis­ lative, and law-enforcement action. Some of this action has been initiated l!J the non-aligned countries as part of their Action Programme for Economic Development. UNCTAD, UNICEF and UNIDO are also plcrying their part. A growing number of countries are banding together to take advantage of bulk purchasiflg and joint qualiry control. Manufacturers too have made a move in the right direction l!J selling certain drugs at reduced prices to the public sector in developi1tg co11ntries.

Yet it cannot be denied that the interests of the developing countries on the one hand, and of the drug and vaccine industry on the other, are not identical. That industt:_y is still attracted Jnain!J 0' the profits it can make in the developed countries : a tvarning sign was given when two well-known firms ceased to prodttce vaccines because of what they felt to be a lack of profitability. The industry has not yet grasped the significance of the tremendous markets that will open up as primary health care gains ground in the less developed countries, nor of the social-and com­ mercial-wisdom of helping countries to develop these markets l!J producing drugs local!J as well as i1nporting them. Moreover the developing countries have not yet themselves ful!J awakened to the potential of economic as well as technical cooperation in drug and vaccine production. I can on!J reiterate what I said in the introduction to my report on the work of WHO in I9J8. Nothing short of an optimal!J coordinated drive throughout the world is needed to bring essential drugs and vaccines to all who need them, and without these essential drugs and vaccines people will not have confidence in primary health care.

Am I convinced that optimal action for health development is taking place since the Dec­ laration of Alma-Ata issued its challenge to the national and international communiry ? There is certainty no room for complacenry in a'!)' country; but neither is there place for pessimism. The goal is there; the wcrys of attaining it are dai!J becoming clearer; and the lesson of the past two years is that if we temper our dreams tvith realism we shall reach our goal in spite of world political and economic malaise.

Director-General

XIV Chapter 1

Poliry Basis.· World Health Assemb!JJ Executive Board and Regional Committees

I.I DURING THE biennum 1978- ciples were adopted in May 1979 by the I 979 the governing bodies Thirty-second World Health Assembly, of WHO played a more active which endorsed the report of the Inter­ role than ever before in shaping the Organ­ llational Conference on Primary Health Care, ization's policies and guiding its work. stressed that strategies should be for­ The Executive Board assumed greater mulated first and foremost by the countries responsibilities, its representatives intro­ themselves, and requested the Director­ ducing certain items at the Health As­ General to take the necessary measures to sembly, summarizing the Board's discus­ ensure that the appropriate priority was sions on the subject, and replying to given to this work (resolution WHA;z.;o). questions raised by delegates. The regional In addition the Health Assembly requested committees also played a noticeably more the Director-General to conduct a study active role, many of them setting up sub­ on the strengthening of WHO's cooper­ committees to deal with such matters as ation in this field with other organizations the programme budget, the General Pro­ within the United Nations system (reso­ gramme of Work, and technical cooper­ lution WHA32.24). ation among developing countries, and also to provide general advisory services r.; Subsequently the United Nations to the Regional Directors. General Assembly, at its thirty-fourth session, in November 1979, adopted reso­ Strategies for health for all by the lution 34/5 8 on health as an integral part of year 2ooo development, endorsing the Declaration of Alma-Ata and appealing to Member States 1.2 Following the Declaration of Alma­ to carry out the actions called for in the Ata in September 1978-calling for the Declaration. The resolution welcomed the development of national, regional and efforts of WHO, UNICEF, and other global strategies for health for all, based agencies in the United Nations system on primary health care-the Executive regarding the goal of health for all by the Board prepared guiding principles for year zooo, and called upon the relevant formulating such strategies.1 These prin- organizations to support WHO's efforts by 1 World Health Organization. Formulating strategies appropriate action within their respective for health for all by the year 2000. Geneva, 1979. Also spheres of competence. It noted with reproduced as Annex 2 to Thirty-second World Health Assemb!J: Resolutions and decisions (WHO document approval the Health Assembly's decision WHAp/1979/REC/1). that the development of WHO's pro-

I POLICY BASIS grammes and the allocation of its resources (resolution WHA3Z.II). (For further details, at global, regional and country level should see Chapter II, paragraphs II.I4-11.24). refl~ct. its c~mmitment to the priority of achievmg th1s goal, as well as the decision to ensure that the global strategy was Programme Committee of the Executive reflected in WHO's contribution to the Board preparation of the new international devel­ I .6 The scope of the work of the Pro­ opment strategy of the United Nations. gramme Committee of the Executive Board was considerably broadened. On behalf I ·4 . At their I 979 sessions the regional ~f the Board it monitored the implementa­ commlttees pledged support in the formu­ twn of the programme budget policy and lation of strategies at the regional level strategy, 1 considering the subject pro­ (resolutions AFR/RC29/RI I, AFRjRC29/RI6, gramme by programme in November I978, SEAjRC32/RI, EURjRC29/R6, EMjRC29A/R7, and on the basis of issues cutting across and WPRjRC30/RII). those programmes in November I979· Its review of the Sixth General Programme of I. 5 An essential component of primary Work concentrated mainly on the extent to health care and a prerequisite for attaining which that Programme is being translated health for all by the year zooo is the into medium-term programmes, and some provision of safe drinking-water and sanitation. of these were reviewed in depth. It also The recommendations of the United Na­ took preliminary action on the preparation tions ~ater Conference (Mar del Plata, of material for the Seventh General Pro­ Argentma, I977) concerning the attain­ ment of safe water supply and sanitation gramme of Work. With regard to the formulation of strategies for health for all for all by the year I99o have accordingly been reflected in WHO's priorities. The by the year 2000 (see paragraph 1.2 above), Thirty-first World Health Assembly called the Programme Committee in I 978 pre­ pared draft guiding principles for the for a determined effort to meet the needs of populations deprived of services; urged Bo~rd's consideration, and in I979 it rev1ewed the current status of activities. governments to mobilize all possible re­ sources and prepare realistic plans ; and 1. 7. Pursuant to resolution WHA 3 1. 3 5, requested the Director-General to streng­ wh1ch requested the Director-General to then technical cooperation with Member present to the Executive Board and Health States in preparing for the International Assembly a comprehensive programme of Drinking-Water Supply and Sanitation De­ research in which WHO is involved the cade, and to promote coordination and Programme Committee in I 978 revi~wed co~peration at the international level (reso­ the evolution of research activities ' in the light lutwn WHA3 I .40). The Thirty-second of the new plan for research management­ World Health Assembly adopted a recom­ with emphasis on strengthening the capacity mendation by the Executive Board at its sixty-third session urging Member States to support the cooperative action for the 1 See World Health Organization. The Work of WHO, I970-I911· Geneva 1978, Chapter I, paragraphs Decade initiated by the United Nations 1.2-1,6, and other related organizations, and re­ 2 The Pr'?gramme Committee's report is reproduced questing the Director-General to coordinate as Appendtx 2 to Executive Board, sixty-third session. WHO's activities in this field with its other ReP_ort on the proposed programme budget for the financial pmod 1980-1981 (WHO document EB63/49). See also efforts for providing primary health care Chapter 4, paragraphs 4.2-4.4 below.

2 THE WORK OF WHO, 1978--1979

of Member States, particularly developing Organizational studies of the Executive countries, to carry out biomedical and Board health services research, and on the par­ 1.9 The work on the Executive Board's ticipation of national scientists in WHO's organizational study on "WHO's role at research activities, with the Organization the country level, particttlar(y the role of the assuming a coordinating role. The Pro­ WHO representatives", 2 was completed early gramme Committee also reviewed a pro­ in I978 and transmitted to the Thirty-first gress report on the work of the Director­ World Health Assembly. The recom­ General's Coordinating Committee on Can­ mendations and conclusions were as cer, which was established in April I978 follows: in accordance with a recommendation made by an ad hoc committee to the sixty-first (I) The donor to recipient "assistance" session of the Board in January of that year. approach should be abandoned and replaced by real cooperation between 1.8 Following the Programme Com­ the Member States and WHO as equal mittee's review of ways and means of partners. reducing the adverse effects of cttrrency flucttta­ (z) The ultimate aim of any collabo­ tions on the programme budget, the ration should be the country's self­ Thirty-second World Health Assembly reliance ; this implies a gradual change adopted resolutions WHA32·3 and WHA32.4, in the mode of collaboration so as to providing a new and flexible way of adapt it, at each moment, to the coun­ dealing with currency fluctuations in I 979 try's real needs. and in I98o-I98I respectively. For each (3) One of the essential functions of the of these periods, the Health Assembly Organization is to collaborate with authorized the Director-General to charge countries in the planning, management against available casual income the net and evaluation of their own health additional costs to WHO under the regular programmes ; this type of collaboration programme budget resulting from the should enable the countries to select difference between the US dollar/Swiss the activities they should undertake in franc rate of exchange used by WHO in order to solve their priority problems, establishing that budget and the UN/WHO and to determine the fields of application accounting rates of exchange prevailing of collaboration with WHO and other at the time the budget was implemented­ cooperating agencies. provided that such charges did not exceed (4) Programming at country level will US$ I 5 ooo ooo during the stated period. place WHO in a better position to Conversely, if there were net savings, the develop its programmes at the regional Director-General was requested to transfer and global levels. such savings to casual income, up to an amount of US$ I 5 ooo ooo in each of the (5) In order to fulfil its role at country periods I979 and I98o-I981. This special level, the Organization should actively casual income facility proved effective seek all means of facilitating dialogue in I979 in protecting the regular budget with nationals at country level, and at from the adverse effects of currency other echelons of the Organization. fluctuations .1 (6) The dialogue between WHO and governments should lead to increased 1 Final figures are given in the Financial Report for 1979. 2 See WHO Official Records, No. 244, 1978, Annex 7·

3 POLICY BASIS part1c1pation of national authorities in, health training m which the Organi­ and responsibility for, the work of WHO. zation should play the role of pioneer (7) WHO should contribute to a more in conjunction with the appropriate equitable . distribution of health re­ educational bodies. sources, both between and within coun­ (I 5) The training referred to in section tries. (I4) should emphasize health manage­ (8) The new methods of collaboration ment ; this training should take place imply a better utilization of all the as far as possible in the regions them­ resources which WHO can mobilize, selves, should be geared to practical whatever their origin. national problems in health manage­ ment, should be based on national (9) Development of the WHO repre­ institutions, and should be organized sentatives' role should be continued jointly for national and international by strengthening their technical func­ health personnel. tions and reducing their representative functions. (I 6) The change in the type of relation­ ship between Member States and WHO ( 10) The function of liaison between requires a re-examination of the Organi­ WHO and the governments, hitherto zation's structures in the light of its performed by WHO representatives, functions. could benefit from new approaches that would make greater use of national I.Io The recommendation in section skills and resources. (I 6) was reiterated by the Health Assembly (I I) Further experimentation should take in resolution WHA31.27, which requested place with the use of national personnel the Director-General to re-examine the as WHO representatives and project Organization's structures in the light of managers. its functions. A managerial study of (I 2) There is a need for continuing unprecedented magnitude was sub­ evaluation of different approaches to sequently undertaken and a report was cooperation and coordination at the prepared for submission to the sixty-fifth country level with particular reference session of the Board in I98o. to the role of WHO representatives, national coordinators and other mechan­ I. I I Extensive work was done during isms, such as national coordinating the biennium on the organizational study committees. on "The role of WHO expert advisory panels and committees and collaborating centres in (I 3) In the light of their functions as meeting the needs of WHO regarding expert defined in the report, the title of WHO advice and in carrying out technical activities representative should be changed to of WHO". It included visits to 2I WHO that of "WHO coordinator", and where collaborating institutions in the Region of national personnel fill this function the Americas and the South-East Asia, their title should be "WHO national European and Western Pacific Regions, coordinator". and participation in the work of the global (I4) New methods for WHO action and regional advisory committees on me­ at country level, together with reorien­ dical research. A report was prepared for tation of the WHO representatives' presentation to the Board at its sixty-fifth functions, require a new type of public sess10n.

4 THE WORK OF WHO, 1978-1979

Technical Discussions for technical cooperation among developing countries (TCDC), was also responsible for I.I2 The Technical Discussions at the organizing the Technical Discussions on Thirty-first World Health Assembly-on this subject at the Thirty-second World "General policies and practices in regard to Health Assembly,2 which focused on the medicinal products; and related international need for political commitment at the 1 problems" -were particularly lively in view highest level to TCDC on the part of the of the many difficulties inherent in the economically developed as well as the production, export and import of drugs. developing countries. It was emphasized The general recognition that the availability that Member States should have a national of essential drugs is a prerequisite for plan and a clear policy for TCDC, backed primary health care permeated the Discus­ by a national health programme ; develop sions. These ranged over problems of a national information system on TCDC ; supply, including local manufacture ; dis­ expand health manpower development, tribution, quality control and selection of particularly in the field of teaching and essential drugs ; traditional medicine ; the research ; provide information on training need for simple and easy-to-follow legisla­ needs and potentials ; and exploit to the tion and regulatory control ; the need for full the possibilities for local manufacture information and education of the public and quality control of low-cost essential and of health personnel at all levels on the drugs. WHO, together with other organi­ proper use of drugs, with special reference zations of the United Nations system and to the responsibility of health personnel, with the developed countries, should play through their prescribing, for the cost a catalytic and supportive role. The of health care. The role of the pharma­ practical measures whereby WHO could ceutical industry was repeatedly stressed : facilitate TCDC included the review of so far it seemed to have seriously under­ existing information services on health estimated the potential of the developing resources ; the promotion of cooperative countries as consumers of basic drugs and projects and joint ventures in the pro­ the enormous size of the markets. duction, procurement and distribution of However, the developing countries them­ essential drugs ; the development of infor­ selves should not lose sight of their mation systems and of legislation to meet responsibility for initiating national action the needs of TCDC in primary health care programmes, based on a political decision and other priority programmes ; and the at the highest level to bring about health formulation of strategies for TCDC as for all-which implies inter alia access to a new and mutually advantageous dimen­ medicinal products for all-and for tack­ sion of the New International Economic ling without delay the causes of drug Order. shortages, both geographical and economic. (For the action taken by the governing r.I4 The Thirty-second World Health bodies in regard to essential drugs and the Assembly, in resolution WHA32.27, urged use of medicinal plants, see paragraphs the Director-General to take into account r.24-r.26 below). the deliberations of these Technical Discus­ sions in the preparation of the Seventh I. I 3 The Regional Office for the General Programme of Work and in all his Americas, which is globally responsible efforts to support countries in the imple-

1 See WHO Chronicle, 32: 280 (1978). 2 See WHO Chronicle, 33: 267 (1979). POLICY BASIS

mentation of the new international develop­ covered a range of subjects (listed in ment strategy. This recommendation was Table LI) mainly relating to two of WHO's listed among the measures to form the major preoccupations-primary health care basis of his proposals for restructuring and the control of communicable diseases. WHO and redistributing its programmes and resources, with a view to redressing the inadequate and intolerably inequitable Programme trends and priorities distribution of health resources throughout the world. I. I 7 The governing bodies devoted close attention to the policy regarding 1. I s The TCDC concept underlay the biomedical and health services research, as discussions in the regional committees in illustrated by the adoption of resolutions both years of the biennium. In the Re­ EB6I.R36, WHA3L3S (see also paragraph 1.7 gional Committee for Europe the use­ above), and WHAp. Is. Moreover, follow­ fulness of the concept as applied to de­ ing proposals made by the regional ad­ veloped as well as developing countries visory committees on medical research, was specifically mentioned, and ways of four of the regional committees discussed avoiding the donor recipient relationship the subject and adopted resolutions in­ in TCDC were discussed. Specific resolu­ dicating priorities for research in their tions on TCDC were passed in one or both respective regions (resolutions AMR/RC3 I/ years by all the other regional committees. R20, EUR/RC28/R4, EMjRC29A/R6, WPRjRC29/ (For further details on TCDC, see Chap­ RIO and WPR/RqojRI8). ter 3, paragraphs 3·3I-3·3S, below). I. I 8 With regard to the malaria control I. I 6 Technical Discussions were held strategy, the Executive Board at its sixty­ at all regional committee sessions and first session appointed an ad hoc committee

Table 1.1 Technical Discussions held during the World Health Assembly and during sessions of the regional committees, 1978-1979

Year Subject 1978 1979

Technical cooperation in the field of health among developing countries ...... Health Assembly Social policy and health development in Africa Africa The present state of child health in the Region ...... Eastern Mediterranean Community health education and information Africa National policies and practices in regard to medicinal products; and related international problems ...... Health Assembly The impact of drugs on health costs: national and international problems ...... Americas Drug policy, including traditional medicine, in the context of primary health care ...... South-East Asia Acute respiratory infections ...... Western Pacific Diarrhoeal diseases, Including cholera, typhoid and paratyphoid Western Pacific The Expanded Programme on Immunization ...... South-East Asia Investigation and control of rheumatic diseases ...... Europe Strategies for extending and improving potable water supply and excreta disposal services during the decade of the '80s Americas Continuing education of health personnel and its evaluation . Europe Study of WHO's structures in the light of its functions . . . . Eastern Mediterranean

6 THE WORK OF WHO, 1978--1979 to assist in preparing a report for sub­ including the psychosocial development of mission to the Thirty-first World Health the child (resolution AMR/RC3 I/R33) and Assembly on the reorientation of the WHO a regional medium-term programme in malaria programme. The Health Assembly family health (resolution EUR/RC29/R4)· subsequently adopted resolution WHA3 1.45 In the Eastern Mediterranean Region a and defined a broad-spectrum programme report on the present state of child health employing all available methods that appear in the Region was examined during the to be useful and feasible within the context Technical Discussions in I978. It was of countries' various economic and social concluded (resolution EM/RC28A/RI 3) that conditions and the epidemiological situa­ the International Year of the Child was a tion in different areas within each country. most appropriate time for the strenuous The Thirty-second World Health Assembly effort needed to attain a significant and adopted resolution WHA32.35, calling for permanent reduction in the prevailing intensified action for development of the high mortality and morbidity rates among programme in Africa. Similar resolutions young children. The resolution called for were adopted at both the I978 and I979 particular attention to children under three sessions of the Regional Committees for years of age ; endorsed the proposal to the Americas (resolutions AMR/Rqo/RI 8 devote a higher proportion of the regulat; and AMR/RC3 I/R30), where a regional plan budget to child health, including the of action against malaria is being developed, programmes on control of diarrhoeal and for the Western Pacific (resolutions diseases and on immunization ; and sug­ WPRjRC29/R I 3 and WPRjRqojR2 I), where gested a special voluntary fund for child Member States were urged to intensify health in the Region. (Work in maternal their efforts and collaborate in training and child health is described under Chap­ and research activities. (Details of the ter 6). malaria programme will be found in Chapter 9, paragraphs 9.2I-9·37, below). I.2I The Thirty-second World Health Assembly took a concerned interest in the I. I 9 The Thirty-first World Health health care of the elder!J. In resolution Assembly, recognizing the crucial im­ WHA32.25, it responded positively to the portance of family health, asked for infor­ decision of the United Nations General mation on the present status of maternal Assembly (resolution 33/52) to organize a and child health in the world to be presented World Assembly on the Elderly in I982, during the International Year of the Child, stressing WHO's leadership role in the I 979 (resolution WHA3 I. 55). Reviewing health care of the elderly and calling on the subsequent report, the Thirty-second the Organization to play a full part in the World Health Assembly outlined a long­ preparations for the World Assembly. term programme for maternal and child These preparations have been entrusted to health care (resolut~on WHA32.42), which the Regional Office for Europe as part of it saw as particularly important in primary its global responsibility for WHO's pro­ health care and in achieving the goal of gramme for the care of the elderly (see health for all by the year zooo. The theme Chapter 5, paragraph 5.28). chosen for World Health Day in I979 was: "A healthy child, a sure future". 1.22 The Health Assembly's continued interest in ways of influencing life-styles 1.20 The regiop.al committees con­ has been evident in resolutions on tobacco sidered various aspe~ts of the same subject, smoking and alcohol-related problems. Force-

7 POLICY BASIS fully underlining the health hazards of General to institute a series of measures to smoking (resolution WHA; I. 56), the Health promote WHO's action programme in Assembly called for expanded activities in this field, and in May I978 the Thirty-first health education and asked Member States World Health Assembly set out the guiding to take economic and social measures to principles for the programme (resolution restrict smoking. In keeping with that WHA31.32). It recognized that the local resolution the theme selected for World production of essential drugs and vaccines Health Day in I98o was "Smoking or is a legitimate aspiration of developing health : the choice is yours". A further countries ; that the establishment of a resolution prohibiting smoking during pharmaceutical industry in countries where official WHO meetings in the Eastern it does not exist requires the transfer of Mediterranean Region was adopted by appropriate technology and investment; the Regional Committee (resolution EM/ that collective purchases of large quantities RC28A/R5)· After the Executive Board of pharmaceuticals would substantially re­ had debated a report on alcohol-related duce their costs ; that there is a need for problems (resolution EB6;.R;o), the Health objective information about pharmaceu­ Assembly pressed for an intensive pro­ ticals, in view of the risk of uncontrolled gramme to control the excessive con­ promotional activity by manufacturers ; sumption of alcohol (resolution WHA;z.4o). and that urgent international action is It again stressed the need for strong required to establish an action programme preventive programmes, including public aimed at strengthening the national capa­ information and education (see also Chap­ bilities of developing countries regarding ter 7, paragraphs 7·I5-7·I9)· local production, quality control, and the selection and proper use of essential drugs. 1.23 The adoption by the Thirty-first The Health Assembly also adopted reso­ World Health Assembly of resolution lution WHA3 I. 33 recognizing the impor­ WHA3 1.28 marked an important step for­ tance of medicinal plants in the health ward in the efforts to control the increasing care systems of many developing countries. number of chemicals in food and the environ­ ment that are potentially toxic and harmful 1.25 In January I979 the sixty-third to health and could contribute to the session of the Board considered a report 2 genesis of cancer and negative genetic prepared by the Ad Hoc Committee on changes. In particular, the resolution Drug Policies that had been established at called for the strengthening of the work its sixty-first session, and adopted resolu­ in this field through the establishment of tion EB63.R2o, which was subsequently a central WHO unit at headquarters for endorsed by the Thirty-second World planning and coordination, and a network Health Assembly in resolution WHA32.4I, of national institutions that would be calling for the establishment of a special assigned specific tasks (see also Chapter I I, programme on essential drugs. paragraphs I 1.9-I I. II). 1.26 Relevant resolutions adopted by 1.24 The sixty-first session of the Ex­ the regional committees included, in I 978, ecutive Board, after considering the report of the WHO Expert Committee on the AFR/RC28/R6, requesting the Regional Di­ rector for Africa to give priority to training Selection of Essential Drugs,! adopted resolution EB6I.RI7 calling on the Director- 2 Executive Board, sixt.y-third session : Resolutions and decisions (WHO document EB63/48), Annex 7· See also 1 WHO Technical Report Series, No. 615, 1977. WHO Chronicle, 33 : 203 (1979).

8 THE WORK OF WHO, 1978---1979 health personnel in the formulation and General on the subject/ adopted resolu­ implementation of national and regional tion EB63.R25 approving the following policies on drugs and medical supplies, proposals of the Director-General : (I) to and EM/RC28A/R2, urging Member govern­ establish-with a view to improving geo­ ments in the Eastern Mediterranean Region graphical distribution in the selection and to designate a formulary committee of appointment of staff-desirable ranges simi­ national experts to establish standard lists lar to those applied by the United Nations of essential drugs. In I979 resolution but adapted to WHO's membership and SEA/RC22/R5 underlined the importance of the size of its Secretariat; (2) to set specific the supply of essential drugs for the targets up to the end of I 98 I for the achievement of the goal of health for all recruitment of nationals of certain Member by the year 2ooo and called for the estab­ States ; and (3) to set specific targets for lishment of a regional drug information the recruitment of women. However, the centre in the South-East Asia Region. Thirty-second World Health Assembly (Further details of WHO's programme on (resolution WHA32·37) requested the sixty­ essential drugs are given in Chapter 8, fifth session of the Board to re-examine paragraphs 8. I 3-8. I 6). the concept of desirable ranges, and the Regional Committee for South-East Asia (resolution SEA/RC32/RI4) expressed con­ 1.27 In recent years WHO has been cern about the adverse effects likely to active in the development of managerial result from the implementation of that processes not only for WHO programmes concept, and urged that the whole matter but also for national health development. be reconsidered. A number of resolutions were adopted by the Board at its sixty-first session and by the Thirty-first World Health Assembly: EB6I.R25 and WHA3J.I2 on country health Health and peace programming; EB6I.R26 and WHAp.II on health programme evaluation ; and 1.29 The governing bodies became EB6I.R32 and WHA31.20 on information increasingly aware of the potential role support. In resolution WHA3 I ·43 the that improvements in health care could Thirty-first World Health Assembly urged play in the promotion of peace. The Member States to develop their managerial Thirty-second World Health Assembly processes for health development in an (resolution WHA32.24) recalled the con­ integrated manner, and requested the tribution that WHO had already made to Director-General to provide support to the strengthening of peace and cooper­ countries in that respect and also to ensure ation between nations, and asked the that WHO's own managerial processes Director-General to report on the further were developed in a like manner. (See also steps which the Organization could take Chapter 2, below.) in the interests of international socio­ economic development and in the imple­ mentation of United Nations resolutions 1.28 The governing bodies have con­ on the strengthening of peace, detente and tinued to urge that increased efforts be made disarmament. to achieve a more balanced and equitable recruitment of professional and higher-graded staff. At its sixty-third session the Board, 1 Executive Board, sixry-third session : Resolutions and after considering a report by the Director- decisions (WHO document EB/63/48), Annex IO.

9 POLICY BASIS

1.30 The Health Assembly adopted a in Cyprus (resolutions WHA31.25 and number of resolutions calling for intensified WHA3Z.I8), assistance in Lebanon (reso­ health cooperation with newly independent lutions WHA31.26 and WHA3Z.I9), and and emerging States and with national continued efforts to improve the health liberation movements recognized by OAU conditions of the Arab population in the (WHA31.46, WHA31.52, WHA32.20, WHA3Z.ZI occupied Arab territories, including Pa­ and WHA32.22). The Regional Committee lestine (resolution WHA31.38). for Africa similarly expressed strong sup­ port for such national liberation move­ * * * ments and for the front-line States in I. 3 z The above paragraphs illustrate southern Africa (resolution AFR/RCZ9/R8 the increasingly close coordination in and AFRjRC29/RI4)· policy matters among the regional com­ mittees, the Executive Board and the I. 3 I The Middle East was also given Health Assembly-a subject that received special attention by the Health Assembly, close attention as one of the essential aspects which called for intensified health assist­ of the study of WHO's structures in the ance to refugees and displaced persons light of its functions.

10 Chapter 2

General Programme Development and Management

2.1 THE THIRTY-FIRST World viewed separately for the purposes of this Health Assembly (resolution report, the two groups are in fact closely WHA3 1.43) urged all Member interlinked. States to introduce, or strengthen where applicable, an integrated process for defin­ ing health policies ; formulating priority National health programme develop­ programmes to translate those policies ment into action ; delivering such programmes through the general health system ; moni­ Country health programming toring, controlling and evaluating them ; 2.3 During 1978-1979 WHO con­ and providing adequate information sup­ centrated on the development and use of port. In so doing Member States were the country health programming process, urged make use of methods developed including the related national processes of under the aegis of WHO ; and the Health programme budgeting, programme evalu­ Assembly requested the Director-General ation, information support, and man­ to continue the integrated development agement training as applied to health by WHO of processes for medium-term programmes. programming, programme budgeting, health programme evaluation, and pro­ 2.4 The Thirty-first World Health As­ vision of information support. sembly (resolution WHA3 r. 12) reemphasized the importance of country health pro­ 2.2 In the past there has been some gramming as a systematic and continuing tendency towards adoption of inappro­ multisectoral, national process, urged Mem­ priate, oversophisticated, disparate and ber States to introduce or strengthen that costly methodologies. In recent years, process in cooperation with WHO and however, WHO has sought to promote with other countries, and requested the approaches to health programme develop­ Director-General: (r) to cooperate with ment and management that are relevant, Member States in the further development practical, unified, and economical. Its and application of country health pro­ activities in this direction can be divided gramming ; ( 2) to promote training in the into two groups : those that deal with the process, as well as the research required development of national health programmes, for its development and application ; and and those that concern WHO's own health (3) to evaluate the progress of country programme development. Although re- health programming throughout the world.

I I THE WORK OF WHO, 1978-1979

2.5 During the biennium therefore the under their five-year plans or other planning integrated management process represented cycles. Six countries in the South-East by country health programming was Asia Region, for example, carried out a further developed, tested and applied by full review of their health programmes. countries in all regions. The process has In the Region of the Americas a health six recurrent and interrelated phases : (I) planning process similar to country health formulation of general health policies, programming continues to be used exten­ strategies, and plans of action; (2) broad sively, and countries are developing their programming ; (3) detailed formulation strategies for the next decade in this of programmes; (4) planning for im­ context. Twenty-two countries of this plementation; (5) management of im­ Region defined or updated their health plementation; and (6) management of policies. programme operations. Although pre­ sented here as a formal sequential process, 2.9 Although in I978-I979 most coun­ country health programming is in fact a tries formalized their policy-making and flexible, realistic process with multiple planning approaches, they varied in the entry-points and information feedback extent to which the procedural steps were relationships. defined. Most countries promoted com­ munity participation and the decentral­ 2.6 Most countries that have initiated ization of management processes, thus facili­ country health programming consider it tating intersectoral action in planning and a suitable management tool for the formu­ management. Several countries adopted lation of national policies, strategies and long-term planning (I 5-20 years) for plans of action for the attainment of their broad programmes, setting objectives health for all by the year zooo and for for coverage by services and improvement primary health care. In the Western of health conditions. The programmes Pacific Region a subregional conference that most frequently emerge as a priority on primary health care recommended the after the programming process are those use of the process as essential for the fully consistent with the primary health planning of such care. care approach. Most countries either 2.7 WHO is currently rev1s1ng its stress the progressive extension of coverage working guidelines for country health by the health services in accordance with programming. Related manuals have a predeterminated schedule, or aim at been developed at country or regional total coverage by either health services level, e.g., the manual on health planning or social insurance. in the Western Pacific. These guidelines and manuals highlight the components 2. I o Emphasis was placed on trrumng of country health programming and in country health programming and related reflect the importance of integrating managerial processes (see paragraph 2.2 I planning and management functions. below). Interregional seminars were organ­ ized for the exchange of experience among 2.8 A total of 42 countries have countries using the country health pro­ adopted some form of country health gramming process or some other formal programming, I9 of them during I978- health planning approach. Four such I979· Other countries continued to use the seminars (two of them funded by DANIDA) process for implementing priority pro­ were organized : two in Bangkok, one in grammes or for formulating programmes Brazzaville, and one in Dubrovnik (Yugo-

I2 GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT slavia). They stressed the importance of encouraging them to exchange their sound managerial processes for national experience. health development in the wider context of socioeconomic development and joint 2.I2 Programme budgeting is closely intersectoral effort ; and noted that the related to the issue of health care financing, old notion of incremental plans per­ which was the subject of a WHO study petuated by planning units, of which group whose conclusions were published the outcome was the formulation of pro­ in I978.1 "Economics and health policy" jects of only limited scope, had given was the theme of a CIOMS Conference way to a new process allowing for greater (Geneva, November I979), which stressed participation. The definition of health the need for exchange of experience among implicit in the concept of "Health for all by countries on methods of financing health the year zooo" and in the Declaration of care and related economic and budgeting Alma-Ata on primary health care imposed a issues. more open forum for the discussion of health programming making for multi­ Evaluation of national health programmes sectoral and multidisciplinary participation, continuous interaction, and joint work-a 2.I3 During I978-I979, general prin­ process stretching from the policy-making ciples for the evaluation of health pro­ level down to the implementation level, i.e., grammes, both at national level and to the health workers carrying out the pro­ within WHO, were discussed and endorsed grammes and to those the programmes by the Executive Board and World Health were intended to serve. The seminar in Assembly (specifically in resolution Dubrovnik concluded inter alia that an WHA3 I. I I). That programme evaluation integral part of national health develop­ should be a built-in part of the develop­ ment strategies should be the develop­ ment process for national health pro­ ment of health management capabilities. grammes is clearly reflected in the pro­ visional guidelines for health programme National health programme bttdgeting evaluation endorsed by the Executive Board (resolution EB6I.RI I) and the Thirty­ 2. I I As an essential part of country first World Health Assembly. Figure 2.I health programming, WHO and Member illustrates the place of evaluation in the States continued to develop the concept health development process. of national health programme budgeting. This includes: (I) the preparation, for 2.I4 In resolution WHA3I.II Member approval by the administrative and legis­ States were urged progressively to intro­ lative authorities, of national, provincial duce and to promote this evaluation or local programme-oriented budgets in process by national health personnel, and all sectors related to health; (2) the pref­ to collaborate with WHO in evaluating erential allocation of resources to priority the impact of the latter's programmes in health programmes ; and thereafter (3) the their own country. During I978-I979, continuing reprogramming of resources progress in this regard was perhaps slow, within budgetary allocations in response but it was steady. A number of countries to change, including changes in priorities. made use of the guidelines mentioned Such programme budgeting is already being carried out in one form or another 1 WHO Technical Report Series, No. 625, 1978 (Financing of health services. RPport of a WHO study by the different countries, and WHO is group).

GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT above, either to test their usefulness or to Region evaluation processes are slowly adapt them to specific local, provincial or taking root but they are mainly being national requirements. Whenever a pilot apJ?lied on a small scale or to special application was worked out jointly with projects rather than to large programmes WHO, as for example in the African and or health services as a whole. In the European Regions, care was taken to Western Pacific Region such evaluation ensure that the outcome not only had is conducted on a regular basis, WHO operational value for the Member State collaborating with national staff. concerned, but also feedback value that would enable WHO to improve the 2.17 The monitoring of evaluation methods applied. With the support of activities in countries was facilitated by the WHO, and sometimes of other agencies, designing and introducing of relevant reviews were made of national health data collection, as part of the development plans in order to draw conclusions as to of national health information systems the coverage, quality, and organization and the support therefor described in of health services in preparation for the paragraphs 2.22-2.27 below. This work next planning period. was done not only for central, but also for provincial, district and local levels of national health services, so as to create a 2. I 5 Subcommittees of the regional committees, or the regional committees basis for the periodic evaluation appro­ themselves, discussed the promotion of priate to each level. evaluation at both regional and national 2. I 8 At an interregional meeting to level. In the European Region, for assess the development of health pro­ example, a consultative group on pro­ gramme evaluation both at national level gramme development of the Regional and in WHO (July I979), one of the major Committee indicated that the impact of issues was the need for better indicators WHO programmes, and of health pro­ for measuring the health status of the grammes in general, could be improved population and for monitoring the delivery by better monitoring and increased use of health care. Work has begun on a list of more sharply defined output indicators. of such indicators that illustrates their usefulness for monitoring progress in the 2.I6 Member countries of PAHOf implementation of strategies for attaining WHO began the final evaluation of the health for all by the year 2ooo. Ten-Year Health Plan for the Americas, which will not only reflect the health Training in national health management situation in this Region but also measure the soundness of the strategies employed 2.I9 An important component of by countries in contributing to the attain­ national health programme development ment of regional goals. In the South­ is training in health management, and East Asia Region, evaluation is part of WHO gives active support to the training the overall health management processes ; of both national and WHO staff in mana­ WHO collaborates with almost all the gerial processes, sometimes in conjunction countries in this Region in such evaluation, with other international agencies. Collab­ e.g., the work carried out jointly with oration with national institutes, such as UNICEF and USAID in Nepal, and with the Institute for Management for East the United Nations Joint Inspection Unit Africa (Arusha, United Republic of Tan­ in Sri Lanka. In the Eastern Mediterranean zania), the Institute for Management and THE WORK OF WHO, 1978--1979

Public Administration (Accra), the National Information support tn national health pro­ Institute for Health and Family Welfare grammes (New Delhi), and the Health Services Development Institute (Surabaya, Indo­ 2.22 In I978 the Thirty-first World nesia), took the form of courses on mana­ Health Assembly (resolution WHA3 1.20), gerial processes. In several regions train­ urged Member States "to develop or ing in health planning and management strengthen their health information sys­ was carried out in the context of technical tems so as to provide adequate support cooperation among developing countries. to their management processes for health development and to contribute to the 2.20 In the Western Pacific Region international exchange of health and related courses in planning and management were information". It also asked the Director held in I978 and I979• for example in General (I) to develop principles for Malaysia and Tonga; and in the South­ national health information systems and East Asia Region a similar course was to collaborate with Member States in held in Thailand. It became apparent that establishing or strengthening such sys­ to institutionalize such courses by associ­ tems, and (2) to continue to develop the ating them with national health develop­ new WHO information system with a ment centres would facilitate their organ­ view to improving WHO's programme ization on a regular basis. One of the aims management and facilitating the inter­ in the Region of the Americas is to advance national exchange of information. such training by the integration of planning/ programming components into health 2.23 The work of the information administration studies at schools of public systems programme thus falls into two health and other teaching institutions; main areas: (a) the operation and develop­ the training covers both broad and detailed ment of the WHO health information programming, budgeting, operational system (described in paragraphs 2.46-2.6I management, evaluation, and information below), and (b) support for the develop­ support. ment of national health information sys­ tems. Part of the strategy for the pro­ 2.2 I In the context of country health gramme, proposed by the Director-General programming, a considerable number of and endorsed by the Executive Board training workshops were held in I 6 coun­ (resolution EB61.R32), is to concentrate tries in I978-I979, in the form of inten­ first on WHO's own system and then, as sive self-teaching experience, mainly for expertise and experience is acquired, to national health administrators. Four re­ intensify collaboration with Member States gional or intercountry workshops were in developing their national systems. This organized, and four educational institu­ does not imply, either in theory or in tions conducted courses on country health practice, that the WHO system can be programming as part of their regular developed or can exist in isolation from training programmes. In the European national systems. Region a workshop (Vienna, I979) advised on the adaptation of the country health 2.24 The development of management programming approach to the specific information systems for Member States requirements of Europe, and made recom­ is part of the management process for mendations for a consequential develop­ programme development described above. ment of its methodology. Some progress has been made in providing GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT information support for each component mation "profile" concept 1 was found useful of that process. However, until valid in some countries for country health experience is gained of how these com­ programming, management and evaluation ponents are integrated in the different purposes. countries, it may not be realistic to envisage a stereotyped national health information "system". WHO's programme development pro­ cess

2.25 During I978-I979, WHO action 2.28 The Thirty-first World Health in regard to national health information Assembly in I978 (resolution WHA3 1.43) systems included: (I) direct support to requested the Director-General to ensure Member States, at their request, for the that managerial methods for health devel­ development of certain aspects of their opment were devised and applied by WHO national systems, and (2) collaboration in an integrated manner ; to promote or with Member States with a view to evolving conduct research on such methods ; to general principles for such systems. collaborate with countries in the appli­ cation of managerial processes for national 2.26 Regional consultations and work­ health development ; to promote training shops on national health information in health management, particularly through systems were held in the African Region learning-by-doing ; to formulate WHO's (Lome, May I979, and Lilongwe, August medium-term programmes wherever pos­ I979), the Region of the Americas sible with an indication of priorities be­ (Washington, February I979), and the tween programmes, based on information South-East Asia Region (New Delhi, from national health development pro­ December I 978). Technical discussions cesses, the current General Programme of on the subject were held in the European Work, programme budget policy and Region (Munich, Federal Republic of strategy, and resolutions of the governing Germany, September I977); and a regional bodies ; and to continue the integrated workshop is scheduled for the Western development of WHO's processes for Pacific Region (Malaysia, June I98o). medium-term programming, programme An international consultation on principles budgeting, health programme evaluation, for a national health information system and information support. During was held in Costa Rica (November I979)· I978-I979 WHO continued to develop The outcome of all these soundings of those four processes. opinion was an important stimulation of interest in national health information Medium-term programming systems, an exchange of experience, and a significant measure of agreement as to 2.29 Ideally, programme development the principles to guide such systems, in WHO should be the result of the proper together with recommendations for action application of national processes for health by Member States and WHO. development in all its Member States, and of the corresponding response of its

2.27 Direct technical support was given to specific aspects of information systems 1 A "profile" is an aggregate of information selected and structured according to established needs and in a number of countries, including Egypt, periodically updated with a view to providing accessible, Kuwait and the Philippines. The infor- standardized and basic information. THE WORK OF WHO, 1978-1979 own programme development processes. 2.32 Some regional offices have set That response should be based on knowl­ up or are setting up complete management edge of national health development pro­ systems that represent the translation of cesses, on regional and global policies, those terms into action. In the Region and on the programme directives of of the Americas, the evaluation system WHO's governing bodies. Thus, medium­ serves as a management tool for technical term programming in WHO should cooperation with Member States and for essentially be the response to national implementation of programmes at all planning in the light of policies that echelons ; it ensures that resources are countries have themselve corporately utilized so that the technical cooperation adopted. responds to national needs as reflected in national health programmes, and it pro­ 2.30 Provisional guidelines for medium­ vides enough flexibility for adaptation to term programming were approved by the unforeseen changes. In the European World Health Assembly in May 1978 Region a complete management system (resolution WHA 3 1. 10). Thereafter, em­ has been instituted and the medium-term phasis shifted from methods, processes programmes were drawn up simultaneously and mechanisms to practical application so as to ensure better horizontal linkages. and to the essential content of medium­ In the Eastern Mediterranean Region the term programmes, i.e., (a) how they implementation of medium-term pro­ respond to national priorities ; (b) how grammes is being closely monitored. The closely they follow WHO's General Pro­ African, South-East Asia and Western gramme of Work; and (c) how they Pacific Regions regularly review their enable WHO to support national, regional medium-term programmes and also use and global strategies for the attainment them for monitoring programme imple­ of health for all by the year zooo, by way mentation. of primary health care. 2.33 The programme development 2.31 The Programme Committee of working group established by the Global the Executive Board (November 1978) Programme Committee (July 1979) had emphasized the setting of targets for the concluded that further development of establishment of WHO medium-term pro­ the concept of medium-term programming gramming ; the dialogue with countries was not at present required but that on medium-term programming ; and the emphasis should be laid on the consoli­ use of the WHO's information system. dation and judicious application of pro­ In November 1979 it emphasized first cesses already in existence. The Medium­ the nature and content of the medium­ term Programming Working Group term programmes; and secondly the need (Manila, 1979) reviewed the provisional for their integrated development and im­ guidelines for medium-term programming plementation, as part of a consistent and stressed the need for medium-term process of consultation and continuing targets and for clarifying the relationship dialogue with Member States. That of medium-term programming to other dialogue should cover policy, strategies, managerial processes. plans of action, general programmes, medium-term programmes, program!Ile 2.34 By the end of 1979 medium-term budgets, operational activities, and the programmes were in operation for most appropriate evaluation and information of the main areas in the Sixth General support at all stages. Programme of Work (1978-1983).

18 GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT

Programme budgeting in WHO more fully into harmony with national budgeting cycles, permitted the greater 2.3~ WHO's programme budgeting involvement of national planners, and process is now fully operational, in accord­ sometimes favourably influenced national ance with the principal approved in resol­ programme budgeting practices. ution WHA2~ .23. Guidelines were issued for the preparation and revision of the 2.38 The new procedures at country proposed programme budget for I98o-I98I level were intended to remove any un­ and were applied, bearing in mind the necessary constraints on Member States programme budget strategy for I978-I98I that might inadvertently be imposed by (resolution WHA29.48), the main objectives WHO's own internal programme budget­ of the Sixth General Programme of Work ing procedures. Lessons have still to be (I978-I983), and WHO medium-term pro­ learned from the application of the process, grammes. This programme budget for e.g., whether those involved take advantage the first time was a completely biennial of the new flexibility offered them to one, in accordance with resolution launch and sustain socially relevant and WHA30.20. unified countrywide programmes, or whether they abuse it by making requests 2.36 The new approach to programme that are only marginally useful, e.g., for budgeting at country level, as applied to isolated projects, supplies, etc. The the preparation of the programme budget experience of preparing the programme for I 98o-I 98 I in accordance with resol­ budget for I982-I983 is needed before ution WHA30.23, met with varying degrees the programme budgeting procedures at of success depending on the region, country level can be properly evaluated, country or local situation. In some in­ refined and improved. The guidelines stances there was a reluctance to depart for the preparation of WHO's proposed from the conventional practice of estab­ programme budget for I982-I983 accord­ lishing at an early stage detailed cost ingly continue the new approach to estimates for all items of expenditure in programme budgeting at country level projects and other activities. Elsewhere, and stress the use of WHO's medium­ the greater flexibility of the new pro­ term programmes to indicate the direction cedures was appreciated, and this per­ of activities. mitted WHO's technical cooperation to be better timed and better integrated with 2.39 In I978-I979 the WHO pro­ national planning and budgeting cycles. gramme budgeting process was greatly 2.37 There were some differences of facilitated by the administration and fi­ op1n10n as to whether deferring the nance component of the WHO information establishment of detailed costs resulted system (see paragraph 2.~4 below). in loss of information and delay in pro­ gramming, or whether on the contrary Programme evaluation in WHO it made for better oriented and more realistic programmes. The reports of the 2.40 The evaluation of WHO pro­ Regional Directors on their experience grammes was introduced as a built-in tended, however, to show that the new continuous process, in conformity with approach resulted in more comprehensive, the Sixth General Programme of Work accurate programme information, prevented and based on the provisional guidelines useless effort, brought WHO practices for health programme evaluation ·(see THE WORK OF WHO, 1978-1979 paragraph 2.13 above). The WHO infor­ end of 1979 to combine and condense the mation system described below provides hitherto largely separate processes of pro­ the information on which that evaluation gramming, evaluation and information. is based. The evaluation of WHO pro­ Particular attention is being given to : grammes however is not progressing as (a) producing management outlines that rapidly as was expected, mainly because are oriented to the present and the future, the concept of continuous evaluation has drawing on the past mainly for the evalu­ not yet taken root in all programmes. ation of performance and of resource Developments in the different regions are utilization ; (b) using such management outlined below. outlines for the monitoring and control of programmes and programme com­ 2.41 In the African Region the evalu­ ponents; and (c) taking into account the ation process was systematically applied evidence provided by the corrective to the selective review of specific pro­ measures represented by reprogramming, grammes during 1978-1979· based on objective evaluation at different levels of activities and their outcome. 2.42 In the Region of the Americas the programme evaluation system (see paragraph 2.32 above) provided the WHO's information .rystem 1 methodology for programming, monitor­ ing and evaluating-in a word, managing­ 2.46 During the biennium WHO's own direct cooperation with governments or information system provided support for the carrying out of regional and sub­ (a) the management of WHO programmes, regional programmes. and (b) the international exchange of information and experience on health 2.43 In the South-East Asia and work. Western Pacific Regions particular attention was given to information support. 2.47 Programme and prriject profiles that include project summaries were introduced 2.44 In the European Region a con­ for WHO activities and are updated sultative group on programme develop­ ment recommended that the provisional annually, as part of the reporting system. (The information component of the pro­ guidelines for health programme evaluation gramming and evaluation system at the should be tested in selected national pro­ grammes 6ver a two-year period, and Regional Office for the Americas is very similar to these profiles and in fact provides should also be tried out on a regional office programme, the results being material for them.) The quality of the content of the profiles, which in the analysed by an outside consultant. More­ beginning did not always adequately reflect over, in order to evaluate the impact of the programme or project in question, programmes, Member States should regu­ larly be asked what action had been taken significantly improved between 1978 and at national level on recommendations 1979· emanating from technical meetings con­ vened by the Regional Office and on the 1 Details of the WHO information system, including resolutions of WHO's governing bodies. its operational components (e.g., reporting and infor­ mation services, administrative management services, 2.45 In the Eastern Mediterranean Re­ and electronic data-processing services), are described in the information systems programme handbook gion an experiment was under way at the issued in 1978 and revised in 1979.

20 GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT

2.48 The new WHO reporting system management and for international exchange was used in two reporting cycles during of experience ; and to the programme of the biennium. Even though the volume appropriate technology for health in pre­ and number of reports was drastically paring and conducting an international reduced, there were relatively few in­ consultation with a view to an information stances in which pieces of information service designed for the periodic and upon­ were left out that would have been obtain­ request dissemination of information on able under the earlier quarterly reporting appropriate technology for health system, discontinued in I 977. Programme (A THIS). All these examples of collab­ profiles were used for medium-term pro­ oration between the information systems gramming and the outcome of such pro­ programme and substantive WHO pro­ gramming was in turn reflected in sub­ grammes or divisions or units have their sequent programme profiles. The new basis at country level and from there reporting system, based on systematic extend to the regional and global levels. updating of the programme profiles, is an effective mechanism for ensuring infor­ 2.50 A joint study was made with the mation flow between echelons with a health and biomedical information pro­ view to programme evaluation (see para­ gramme to determine the feasibility of an graphs 2.4I-2.46 above). international health-related information ser­ vice (HERIS) dealing specifically with selec­ 2.49 Direct technical services were given ted public health literature that at present is in connexion with the technical, oper­ not covered by any international infor­ ational, administrative, reporting and evalu­ mation service. This work (described in ation aspects of a number of programmes. Chapter I3, paragraphs I3.30-J3.3I) is For example, in I978-I979 the infor­ carried out in collaboration with several mation support for the Special Programme national experts and institutions, including of Research, Development and Research the United States National Library of Training in Human Reproduction included Medicine, which runs the MEDLARS the operation and maintenance of a manage­ system. ment information system for financial and administrative data on projects, grants, 2.5 I In addition to such support to institutions and individual scientists ; data­ individual technical programmes, the infor­ processing services were also provided mation systems programme coordinates for the studies on various fertility regu­ the various information support services, lation methods that are being carried out identifies the need for other information in a number of centres. Support was services that do not fall under the responsi­ given to the Special Programme for bility of any specific technical programme or Research and Training in Tropical Dis­ administrative division, and promotes the eases in conducting basic management development of such services. studies and developing a management information service on individuals and 2.52 During I978-I979, experience was institutions related to that programme, gained on the feasibility of a rationalized along with provision of the necessary information service for certain day-to-day computing services. Support was also needs of organizational units. Work was given to the Expanded Programme on undertaken on a comprehensive directory of Immunization in the development of a persons and institutions related to WHO pro­ reporting system both for programme grammes. In I979 this master directory

2I THE WORK OF WHO, 197S-1979 became partly operational, with 67 ooo information systems programme, the for­ entries out of a potential 110 ooo. Its main mer at headquarters through the Geneva­ current use is in the addressing and dis­ based International Computer Centre (ICC). tribution of WHO documents, but it is There are 65 computer applications, and being increasingly used for programme WHO payments to ICC in 1978 and 1979 management purposes. The master direc­ were US$ 1.4 million and US$ 1.6 million tory is primarily the collation of more than respectively (the increase is due to an 43 hitherto separate and scattered lists, increase in costs and not to a heavier directories, rosters, etc., but it has a poten­ workload). An important change in tial for a variety of other applications and electronic data-processing was made in should prove a useful guard against January 1978 when the bulk of the com­ wasteful duplication. puter programming work, hitherto carried out by WHO staff programmers, was z.53 Requests to Member States for contracted out to commercial firms. By the completion of questionnaires are now and large this arrangements proved satis­ monitored by interprogramme committees factory. Furthermore, in order to permit at regional offices and headquarters. In an increased workload without a cor­ addition, records are now kept at head­ responding increase in costs, WHO and quarters of all questionnaires sent to Member ICC in 1979 began a review of the feasi­ States, and the replies received. As a bility of distributing the data-processing consequence there was a sharp decrease workload between ICC and a minicomputer during the biennium in the number of installed in the headquarters building, the questionnaires sent to Member States, latter to be used for day-to-day work or a decrease that was facilitated by the fact for processing voluminous data. that relevant information from countries is systematically maintained and available z.56 Throughout 1978-1979, the from the country, programme and pro­ policy of decentralizing electronic data­ ject profiles (see paragraph z-47 above). processing and word-processing services z. 54 The computerized administration to the regional offices was continued. and finance information !)Stem, which is an Thus in July 1979, after a feasibility study integral part of the new WHO information carried out with the Regional Office for system, provides inter alia support for the Africa, the acquisition of a minicomputer preparation, consolidation and finalization by that Office was recommended. Com­ of the operations required in establishing puter applications are being introduced the biennial programme budget. Specifi­ in such a way as to familiarize staff with cally, the most important budget and the use of the equipment, and are followed finance components of the system (related by storage, updating and selective retrieval to budget preparation, budget control, of profiles, in the expectation that by expenditure accounting, general ledger 1982-1983 the computer will take over entries, and payment of claims) became some of the administrative and financial operational during 1978-1979, when plans chores. were also worked out for extending the system to budget and finance operations z.57 In late 1978, the Regional Office in the regional offices. for the Americas upgraded its computing facilities and took the opportunity of z. 55 Electronic data-processing and word­ ensuring that its equipment was compatible processing services are also provided by the with that used at WHO headquarters.

zz GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT

2. 58 In 1979, the Regional Office for 2.6o During 1978-1979 a review was Europe installed a minicomputer, fully made of commercially available word­ compatible with that of the African Re­ processing equipment. After experience gional Office, which is being used inter gained from the equipment used exper­ alia for some of the basic administrative imentally at headquarters and in two and financial operations. The Regional regional offices, a simple standardized Office for Europe is also the pilot regional type of word-processing equipment that office for certain computer applications met certain compatibility requirements was and for training staff from other chosen and was installed both at head­ regions. quarters and in the Regional Offices for the Americas, Europe, and the Western 2.59 The Regional Office for the Pacific. Western Pacific, in collaboration with the National Computing Centre of the Philippines, by the end of 1979 had con­ 2.61 The involvement of nationals in the cluded a feasibility study for a mini­ development of the information systems computer that will gradually take over programme increased during the biennium, financial, administrative, and statistical when they participated as temporary ad­ operations. The Regional Offices for visers or consultants in most progress South-East Asia and the Eastern Mediter­ and evaluation meetings. National services ranean carried out similar studies, but for were also involved in designing or imple­ technical reasons (related to the suppliers' menting certain aspects of the programme, inability to provide adequate maintenance sometimes under contract, e.g., the National in those geographical areas) no decision Computing Centre of the Philippines men­ has yet been taken. tioned in paragraph 2. 59 above. Chapter 3

Coordination

3.1 FOLLOWING the International paratory Committee (New York, June Conference on Primary Health 1979), the Director-General's representa­ Care and the Declaration of tive spoke on the new approach being Alma-Ata (1978) the coordination of taken by WHO to attain these two main WHO's policies and programmes with objectives of the Organization. those of other organizations-both within and outside the United Nations system­ 3·3 At the same time the Director­ centred on ensuring that primary health General sought the views of various inter­ care and the worldwide social objective of national development experts on the con­ "Health for all by the year 2ooo" were tribution that health development could properly introduced into other intergovern­ make to the New International Economic mental and interagency forums. Order (this, incidentally, will be the subject of the Technical Discussions to be held at 3. 2 The best example of this is the the Thirty-third World Health Assembly action taken by the Director-General with in 198o). The new International Develop­ respect to the new International Develop­ ment Strategy is being formulated within ment Strategy for the nineteen-eighties, the context of the New International Econ­ which in accordance with the decision omic Order, to which it must ultimately taken by the United Nations General contribute. The subject of health and the Assembly at its thirty-third session (resol­ New International Economic Order was ution 33/193) is being formulated by a discussed at the regional committee meet­ Preparatory Committee open to all States. ings in September and October 1979. The Director-General proposed that only two basic documents on the health sector 3·4 While the work of such United should come before the Preparatory Com­ Nations bodies as the General Assembly mittee : the report of the International and the Economic and Social Council Conference on Primary Health Care,! and remained of central importance for the the policy statement entitled "Formulating deliberations of WHO's governing bodies, strategies for health for all by the year a major effort was made to further inter­ 2ooo".2 At the second session of the Pre- agency cooperation on key items defined by governments as well as by the organ­ 1 World Health Organization. Alma-Ala r978: izations in the United Nations system. Primary health care. Geneva, 1978. 21World Health Organization. Formulating strategies Papers were submitted by WHO to the for health for all by the _year 2000. Geneva, 1979· United Nations on such subjects as the COORDINATION role of women in development, the combat broader governmental awareness of the against apartheid, a programme for disabled importance of health work in relation to persons, health care of the elderly, the overall socioeconomic development. International Year of the Child, and Evidence of this was the resolution of the assistance to certain specified developing United Nations General Assembly, on countries. WHO also rook an active part health as a integral part of development in preparing for the United Nations (November 1979), which endorsed the Conference on Science and Technology Declaration of Alma-Ata and the recom­ for Development (Vienna, 1979) 1 and in mendations of the International Confer­ following up the recommendations made ence on Primary Health Care, and stressed at the United Nations Water Conference that the new International Development (Mar del Plata, Argentina, 1977).2 Those Strategy should take fully into account the two subjects were also debated in relation global strategy for primary health care. to better and more effective coordination arrangements. Similarly, information sys­ tems, action against drug abuse, the Nongovernmental organizations formulation of long-term development objectives, the programme budget planning 3.6 At the end of 1979 there were processes of the United Nations system, I 2 3 nongovernmental organizations in and joint information activities on human official relations with WHO, seven of rights were the subject of interagency which had been admitted during the consultation. WHO was fully involved biennium. A complete list can be found in the preparations for the World Con­ in Annex 3 to this report. ference on Agrarian Reform and Rural Development (Rome, July 1979). At the 3. 7 Certain new measures designed to July 1979 session of the Economic and enhance collaboration with nongovern­ Social Council (Geneva), the Director­ mental organizations were introduced in General impressed upon Council members 1979. Their main aim is to focus collabor­ the measures being taken within the health ation more specifically on WHO's priority sector to ensure health for all by the programmes by observing the principle of year zooo by means of primary health care jointly agreed frameworks for collaborative and the national strategies formulated to activities between WHO and nongovern­ that end. mental organizations already in official relations with the Organization or wishing 3·5 Coordination and collaboration to establish such relations. with other organizations and institutions of the United Nations system at head­ 3.8 An interesting development during quarters and regional office level make the biennium was the increasing call made for more effective action at country level. on the pool of expertise that these non­ Clearly, the measures taken by the Organ­ governmental organizations represent. ization in 1978-1979 brought health and health-related issues to the attention of government officials other than those of Extra budgetary sources of funds the ministry of health, and thus created a 3·9 The Voluntary Fund for Health

1 See also Chapter 4, paragraphs 4.1o--4.12. Promotion, one of the most important 2 See also Chapter II, paragraphs II.I4-II.2I. sources of funds for health development THE WORK OF WHO, 1978-1979

external to WHO's programme budget, try Foundation (Sasakawa Memorial Health in I978-I979 increased by US$2 424 o63 Foundation) maintained its substantial con­ (or 3.6o%) over the previous biennium. tribution to selected programmes. Follow­ This is evidence that the countries con­ ing the Alma-Ata Conference, the contribu­ tributing to the Fund recognize the need ting community whole-heartedly endorsed to accelerate the momentum of support for primary health care as a cornerstone of the Organization's work, as called for by WHO's strategies. This approach was numerous Health Assembly resolutions. emphasized in the description of priority activities suitable for extrabudgetary fund­ 3.Io To obtain increased resources ing, as given in the project catalogue that for the Organization's priority programmes, WHO keeps for the convenience of the Secretariat Extrabudgetary Resources potential donors. Committee organized a series of meetings (November I978), at which representatives 3. I 2 A meeting on the financing of from the contributing community, the primary health care programmes in Asia developing countries and WHO were able (New Delhi, July I979) brought together to exchange ideas on the Organization's ten developing Asian countries, official present activities and future plans. A development assistance agencies, UNDP, direct outcome of these meetings was the UNFPA, UNICEF, WFP, the Asian De­ decision to create the Health/ zooo Re­ velopment Bank, the Islamic Development sources Group. It will advise on the Bank, and nongovernmental organizations. mobilization and rationalization of bilateral The results were positive, as evidenced by and multilateral resources to meet the the 95 projects submitted by the Asian Organization's goal of "Health for all countries and the fact that WHO's function by the year 2ooo". The Resources Group as coordinator of international resources will have at its disposal a Primary Health for health development was welcomed by Care Fund. It is hoped that donors' all participants. This meeting opened contributions to this Fund will be sufficient new avenues for collaboration at country to provide "seed" money to enable coun­ level as a first step towards ensuring the tries with primary health care programmes translation into practice of the recom­ to begin activities, and "initiative" money mendations of the Alma-Ata Conference. for countries where reinforcement of activity seems desirable. The Resources 3·I3 A newsletter, "WHO Action", Group is to meet for the first time in illustrating the use of extrabudgetary re­ April I98o and will include representatives sources, was prepared and widely circu­ from developed and developing countries, lated during the biennium and was well UNDP, UNFPA, UNICEF, the World received. Bank, and selected nongovernmental organ­ izations. 3. I 4 An agreement was concluded between WHO and the Islamic Develop­ 3. I I During the biennium sizeable con­ ment Bank. Working arrangements with tributions were received from the tradi­ the African Development Bank were for­ tional donors, notably Australia, Canada, malized by an expanded memorandum Denmark, Federal Republic of Germany, of understanding. Also, close working Netherlands, Sweden, Switzerland, the relations were maintained with the Asian United Kingdom, and the United States Development Bank, which is investing to of America. The Japan Shipbuilding Indus- an even greater extent in the social sector. COORDINATION

3. I 5 Collaboration with the Commis­ Pacific area ; and preparatory work in sion of the European Communities and connexion with the establishment of a new with the Council for Mutual Economic Mediterranean zoonoses control centre. Assistance was formalized. Support was also continued to various country projects, and to the WHO health United Nations Children's Fund programme being carried out in China (see paragraphs 3.29 and 3.30 below). 3.I6 The UNICEF/WHO Joint Com­ mittee on Health Policy, at its twenty­ 3.20 The debates in the UNDP Govern­ second session (Geneva, January I979), ing Council on the role and activities of considered a joint study on the water UNDP gave particular importance to the supply and sanitation components of pri­ promotion of national self-reliance, and mary health care and adopted the recom­ the development and improvement of the mendations contained in that study. It techniques of country programming and also made recommendations on training of planning, implementation and evalua­ in maternal and child health and on child tion of programmes-subjects which are mental health. all of primary importance to WHO. The Council criticized the slow progress in 3. I 7 One of the main topics discussed programming intercountry activities and at the session was the follow-up to the decided to carry out a review of such Alma-Ata Conference, whose report will be programming. the main framework for future action of both UNICEF and WHO. It was decided 3.2I Other subjects of joint UNDPj that the subject of the next UNICEF/WHO interagency studies were : programme im­ study (for consideration by the Joint plementation, the role of qualified national Committee in I98I) will be: "Country personnel in the social and economic decision-making for the achievement of development of developing countries, and the objectives of primary health care". an examination of experience in country programming. 3. I 8 Because of the increasing decen­ tralization of responsibility in both organ­ 3.22 One interesting organizational de­ izations, arrangements for ensuring close velopment stemmed from United Nations collaboration between WHO and UNICEF General Assembly resolution 32/I97 on staff at local level were under review at the the restructuring of the economic and end of the biennium. social sectors of the United Nations system, the Annex to which states that : United Nations Development Pro- "On behalf of the United Nations system, gramme overall responsibility for, and coordination of, operational activities for development 3. I 9 UNDP continued or initiated sup­ carried out at the country level should be port to WHO's major programmes. These entrusted to a single official. . . who should included the Special Programme for Re­ exercise team leadership and be responsible search and Training in Tropical Diseases; for evolving, at the country level, a multi­ the diarrhoeal diseases control programme ; disciplinary dimension in sectoral develop­ the International Drinking-Water and Sani­ ment assistance programmes ... " This tation Decade, where WHO acts as lead team approach under the leadership of a agency ; bulk purchasing and quality con­ "single official" is aimed at better inter­ trol of pharmaceuticals for the South sectoral planning and interministerial and THE WORK OF WHO, 1978-1979

Table 3.1 World Food Programme: Commitments to projects, 1978-1979

Projects approved Projects approved from 1 July 1977 from 1 July 1978 Nature of project to 30 June 1978 to 30 June 1979 No. Amount No. Amount

All projects US$ million US$ million Development aid 51 272.6 61 382.7 Emergency aid . 37 96.1 109 79.0 88 368.7 170 461.7

Health-related projects Health promotion • . • ...... 6 29.0 11 97.7 Institutional feeding ..•• o •••• 10 68.0 10 21.4 Teaching institutions . o ••••••• 4 20.2 7 18.7 Community housing and development . 2 5.8 7 60.9 22 123.0 35 198.7 interagency reviews, and at encouraging role in evaluating WFP activities was national decision-making bodies to give reinforced, and led to the formulation of increased attention to health as an integral a "Guideline for the measurement of and essential part of the socioeconomic nutritional impact in projects assisted by development process, and to its crucial the World Food Programme and other role in achieving the New International agencies". Economic Order. The "single official" 3.25 The selective use in food pro­ will normally, but not necessarily, be the grammes of vitamin-A-enriched dried skim­ resident representative of UNDP. While med milk has now become regular practice, the functions of this country-level co­ facilitated by the cooperation of several ordinator will be of considerable opera­ donor governments that can deliver the tional importance, the lines of authority commodity, enriched or non-enriched as and communication between WHO repre­ the circumstances of the programme re­ sentatives at country level, i.e., the WHO quire. The helpful role of the International programme coordinators, and other levels Dairy Federation should be acknowledged, of the Organization remain unchanged. since it was instrumental in making this 3.23 WHO and the South Pacific Com­ development possible. rrusslon collaborated in preparing for the 3.26 Because of its pioneering nature, Conference of Ministers of Health of the the basic rural health services project in South Pacific Countries/Areas on Technical Sudan, which has a food aid component, Cooperation in Pharmaceutical Supplies made slow but steady progress. The (Manila, November 1979). experience gained proved useful both to World Food Programme the beneficiary government and to the several organizations cooperating in the 3.24 It will be seen from Table 3.1 project. above that assistance to WFP's health act1v1t1es, which had decreased in United Nations Volunteers 1976-1977, regained momentum in the 1978-1979 biennium, notwithstanding the 3.27 The useful role played by United unusually large sums that were devoted Nations volunteers in UNDP-financed pro­ to emergency aid operations. WHO's jects led WHO to consider the utilization

28 COORDINATION of such volunteers in projects financed research development project -which forms from its regular budget. Three programmes part of UNDP's assistance to China under were initially selected : the Expanded Pro­ the basic standard agreement signed in gramme on Immunization, and the pro­ June I979· grammes for prevention of blindness and for control of schistosomiasis. By the end of the biennium five volunteers had been Technical cooperation among develop­ recruited for assignment to projects in ing countries Democratic Yemen, the Sultanate of Oman, the Syrian Arab Republic and the Yemen 3. 3 I The concept of technical cooper­ Arab Republic. They are additional to ation among developing countries (TCDC) those working in UNDP-financed pro­ was described in the last biennial report.1 jects for which WHO is the executing The Thirty-first World Health Assembly agency. (resolution WHA 31.4 I) again underlined its importance for the technological liber­ 3.28 Most of the volunteers come from ation of developing countries, particularly developing countries, in itself an illustration in research, development and training and of technical cooperation among such coun­ in the exchange of experience and infor­ tries. mation on health care ; the Health Assembly called on regional committees, Member Collaboration with China States and the Director-General to take action that would promote TCDC in the 3.29 Technical cooperation between field of health. The Regional Office for WHO and China was formalized by the the Americas was designated as focal point signing on 5 October I 978 of a Memor­ for TCDC work. andum to govern cooperation in health activities. Under the terms of the agree­ 3·32 A United Nations Conference on ment, several collaborating centres were Technical Cooperation among Developing designated to carry out research as part Countries was convened in Buenos Aires of a WHO collaborative programme ; (August/September I978). WHO partici­ Chinese specialists were trained abroad in pated fully in the preparations for the new techniques by means of study tours, Conference and was represented at all fellowships and research training grants ; meetings of the Preparatory Committee visits to China of leading scientists were and of the Inter-Agency Task Force on organized under WHO auspices ; and the subject. The Buenos Aires Plan of equipment was provided to enable national Action that emerged from the Conference institutions to improve their health and was consonant with WHO's view of research services. WHO also collaborated TCDC and was studied in depth, both at with UNFPA on activities in China. headquarters and the regional level, in the light of its implications for WHO. 3.30 Under the UNDP/WHO expanded training programme on primary health 3·33 In the policy statement "Formu­ care and public health in China, the series lating strategies for health for all by the of study tours and training courses in China year 2ooo" (endorsed by the Thirty- for participants from developing countries continued. WHO is moreover the execu­ 1 World Health Organization. The work of WHO ting agency for the health manpower and I97D-I911· Geneva, 1978, pp. 3-l· THE WORK OF WHO, 1978-1979 second World Health Assembly), WHO's essential drugs. Representatives of min­ global role was defined as that of creating istries of health of subregionally grouped mechanisms to ensure the timely and countries met to develop programmes appropriate exchange of information among within the TCDC context. countries interested in this type of tech­ nical cooperation. Its role at regional 3. 3 5 "Technical cooperation in the level was to develop further such mechan­ field of health among developing coun­ isms. Consequently the Regional Com­ tries" was also the subject of the Technical mittee for Africa established a Standing Discussions at the Thirty-second World Committee on TCDC, whose recommenda­ Health Assembly, which are reported in tion for the establishment of three sub­ Chapter I, paragraphs I. I 2-I. I 5, above. regional working groups to meet annually it endorsed. The Regional Committee for the Americas requested the Regional Di­ Emergency relief operations rector to establish a working group at high policy level to study TCDC in the Region 3.36 During the I978-I979 biennium and to set up an information bank to the traditional forms of action in response provide Member countries with details of to emergency situations due to natural or the resources available for TCDC. In other disasters, consisting mainly of im­ South-East Asia the Regional Office estab­ mediate aid in the form of urgently needed lished a task force to deal with all aspects medical equipment, drugs, vaccines and of TCDC. The Regional Office for the other medical supplies, continued ; details Eastern Mediterranean proposed that an are given in paragraphs 3·44-3·56 below. ad hoc consultative committee should advise In this period, however, the first steps the Regional Director on programme were taken to promote disaster prepared­ priorities and the use of TCDC principles ness on the part of Member States. in strengthening technical collaboration between countries. (The Regional Com­ Disaster preparedness mittee had already adopted resolutions in I975 and I976, urging the more affluent 3·37 Technical cooperation with countries of the Region to help others to disaster-prone countries increasingly aimed improve their health services, and a at improving the national capacity both to significant part of the regional programme take preventive measures and to remain has since benefited from such collabor­ more effectively in control of emergency ation.) In the Western Pacific the Regional situations. This involved WHO in activities Office established a subcommittee and a relating to the public health management of focal point to coordinate TCDC activities, emergencies, research on the epidemiology which the Regional Committee at its of disasters, studies of populations at risk, twenty-ninth session decided should focus assessment of needs and priorities in the on primary health care, pharmaceuticals, event of mass casualties, and patterns and drug management and control. of disease and disease control following catastrophes. 3·34 At country level the examples of TCDC covered primary health care, en­ 3. 38 Fellowships were used to train vironmental health, training of health per­ staff from disaster-prone countries in dis­ sonnel, and health research ; specific activi­ aster management, the intention being ties were being developedjin!relation to that ministries of health should possess COORDINATION key personnel capable of promoting organ­ 3·43 Since the systematic study of izational and operational efficiency in disasters is a fairly recent discipline, an dealing with emergencies. The first inter­ attempt is being made to retrieve and regional seminar on emergency care in organize the documentation on the subject. natural disasters was held in 1978 in A manual on the management of nutri­ Manila, with the collaboration of the tional emergencies in large populations was Government of the Philippines, the Office published in 1978/ and a guide to emer­ of the United Nations Disaster Relief gency health management after natural Coordinator (UNDRO), the International disaster is being prepared in the Americas. Civil Defence Organization, the Inter­ WHO collaborated with the Steering national Hospital Federation, the Inter­ Committee of the League of Red Cross national Union of Architects and the Societies and other voluntary organizations League of Red Cross Societies. Courses in compHing Country fact sheets on 91 were also held by the Regional Offices for disaster-prone Member States. Africa and for the Americas. Emergenry relief 3·39 Under a grant from the Govern­ ment of Belgium, agreements were made 3·44 As in the past, WHO participated with Louvain University for research on fully in the provision of emergency assist­ disaster epidemiology and management. ance by the United Nations system, its The University will also provide training work being carried out in close collabor­ facilities. ation with UNDRO, UNEO (United Nations Emergency Operation), UNICEF, 3.40 In the Regional Office for Africa, UNHCR, FAO, the International Com­ a Permanent Committee for Emergency mittee of the Red Cross, the International Relief Operations was set up in 1978. League of Red Cross Societies, the Com­ Emergency supply depots were maintained mission of the European Communities, at five key centrell in Africa. In other and other institutions and nongovern­ regions, regional officers were designated mental organizations active in disaster to act as focal points for disaster planning work. Memoranda of understanding were and relief, and assure coordination with signed with UNDRO and UNEP, out­ headquarters. lining the modalities of coordination and collaborative action. 3·4 I The Region of the Americas is particularly vulnerable to earthquakes, vol­ 3·45 Mechanisms for technical cooper­ canic eruptions and hurricanes. A disaster ation between developing countries are of unit in the Regional Office became oper­ particular value in this area, since in ational in 1978, and a pilot programme in disasters and emergencies Member States preparedness for emergencies is under way are increasingly seeking and using the for the disaster-prone countries of the services of other countries. To give only Region. two examples : in the South-East Asia Region, experts and material aid from 3.42 WHO contributed to the inter­ India and Sri Lanka were provided to national multidisciplinary Conference of Maldives during the cholera epidemic of Experts for the Defence of Society against 1 Natural Disasters in the Mediterranean Ville de Goyet, C. de, et al. The management of nutritional emergencies in large populations. Geneva, World Basin (San Marino, October 1979). Health Organization, 1978. THE WORK OF WHO, 1978--1979

January I979; and in the African Region, Comoros (shortage of medical supplies) ; Zambia hosted a seminar on the manage­ Congo (yellow fever) ; Ethiopia (drought, ment of mass casualties, for health workers epidemics); Gabon (cholera); Gambia from Angola, Botswana, Mozambique and (power failure) ; Ghana (yellow fever, the United Republic of Tanzania. drought) ; * Guinea (shortage of surgical supplies); Madagascar (cyclones); Malawi 3.46 In addition to the action at global (epidemics); Mali (drought, epidemics); level, assistance in and planning for Mauritania (epidemics); Mauritius (meas­ emergencies and disasters were also carried les, malaria campaign) ; Mozambique out by the regional offices and under the (influx of refugees, epidemics, cyclone) ; * various programmes of the Organization. Niger (shortage of medical supplies) ; * These are reported under the relevant Rwanda (influx of refugees, cholera); * headings. Senegal (cholera); Sierra Leone (shortage of medical supplies); Togo (haemorrhagic 3·47 Earthquakes in the European Re­ fever); Uganda (military action); *United gion, hurricanes in central America, cyc­ Republic of Tanzania (cholera, floods); lones in Asia, epidemics in Africa, the Upper Volta (cerebrospinal meningitis); plight of refugees in South-East Asia, and Zaire (influx of refugees, cholera, drought) ; the escalation of the operations of liber­ Zambia (bombing raids).* ation movements in southern Africa-these and other events made particularly high Chad. To redress the health situa­ demands on WHO's resources during I978 tion following the civil war in and I979· The Organization was able to Chad, WHO contributed US$ mobilize urgently the funds it needed : 5o ooo from its regular budget ; items of expenditure ranged from US$720 an additional $u6 ooo was mo­ for a single laboratory refrigerator, to bilized from funds made available US $3 I4 ooo for a range of essential byUNEO. paediatric equipment. Approximately Ghana. To repau the ravages of US $20 ooo ooo was spent on such emer­ drought and fight an epidemic of gency assistance, the bulk of the money yellow fever, WHO procured coming from extrabudgetary funds. The drugs, vaccines and other medical emergencies in which WHO took part in supplies amounting to $3 96 3 39 relief operations during I978-I979 are for the Commission of the Euro­ listed below, by region. A few of the pean Communities. operations (marked by an asterisk) are described in detail, as examples. Mozambique. WHO contributed $2o ooo to combat the damage to health centres caused by cyclone. African Region An additional $I I 9 2 36 was pro­ vided for the emergency campaign 3.48 Angola (influx of refugees, epi­ against cholera. demics); Benin (movement of displaced persons, thunderstorms); Botswana (cere­ Niger. In relation to the Inter­ brospinal meningitis) ; Burundi (shortage national Year of the Child, ur­ of medical supplies) ; Cape Verde (epi­ gently needed medical supplies demics); Chad (civil strife, drought); * and equipment for child health

* Details given at end of paragraph. * Details given at end of paragraph. COORDINATION

were supplied with the $3 I 4 ooo contributed by UNDRO following contributed by UNEO. the eruption of the Soufriere volcano in April 1979. Technical R1vanda. To combat a severe epi­ advice was given by the Regional demic of cerebrospinal meningitis, Office for the Americas. Rwanda received technical aid from WHO and $29 762 worth of South-East Asia Region medical supplies contributed by the Government of Switzerland. 3.50 Bangladesh (influx of refugees, floods); * Burma (mass population move­ Uganda. In I 979 military action ments); India (encephalitis epidemic, cyc­ disrupted the health services and lones, floods) ; Indonesia (influx of re­ caused shortages of medical sup­ fugees) ; * Maldives (gastroenteritis epi­ plies in the country. WHO con­ demic); Nepal (outbreak of encephalitis); tributed $55 ooo from its regular Sri Lanka (cyclone); Thailand, influx of budget to assist in restoring ser­ refugees, floods). vices to normal. Bangladesh. WHO collaborated Zambia. Air attacks directed against with UNHCR, UNICEF and the liberation movements based in League of Red Cross Societies in Zambia resulted in considerable assisting the refugees from Burma. damage to the health services of US $zoo ooo worth of emergency that country. In April I979 WHO medical supplies were procured contributed $I9 ooo for assistance on behalf of UNHCR and shipped to victims of such bombing raids. at advantageous rates negotiated for humanitarian action. Collabor­ Region of the Americas ation continued in Burma as the refugees were resetded in their 3·49 Belize (hurricane); Bolivia (floods); homeland. Costa Rica (influx of refugees) ; Dominica (hurricane); Dominican Republic (hurri­ Indonesia. The influx of several cane);* Guyana (power failure); Honduras thousand Vietnamese refugees and (influx of refugees) ; Jamaica (floods) ; "boat people" into Indonesia put Nicaragua (civil strife) ; Paraguay (floods) ; considerable strain on the country's St Vincent (volcanic eruption).* health resources. WHO obtained the services of two public health Dominican Republic. In August I 979 advisers from the Center for hurricanes caused extensive dam­ Disease Control, Adanta (USA), age to the country. Immediate to assess the sanitary conditions contributions were channelled in refugee camps and advise on through UNDRO, the US$56 ooo the health measures required. donated by the Government of the Netherlands being used for European Region emergency health assistance. 3·51 Portugal (floods); Spain (explo­ St Vincent. WHO procured med­ sion/fire) ; Turkey (resurgence of malaria) ; ical supplies with US $10 ooo Yugoslavia (earthquake).*

* Details given at end of paragraph. *Details given at end of paragraph.

33 THE WORK OF WHO, 1978-1979

Yugoslavia. A series of earthquake JDhilippines. Some 10 ooo to 50 ooo tremors of exceptional violence refugees from South-East Asia struck the southern coast of the were expected at the reception country in April/May 1979. Staff centre in Palawan Province in were sent from the Regional late 1979. Emergency measures Office for Europe and from head­ were taken to ensure a malaria­ quarters to assess the consequences free area and to protect the health for the health services and establish of both the refugees and the post-disaster primary health care surrounding host population. facilities.

Eastern Mediterranean Region National liberation movements recognized l?J 3· 52 Afghanistan (floods) ; * Cyprus the Organization of African Unity or the (influx of refugees); * Democratic Yemen League of Arab States (cholera) ; Lebanon (civil strife) ; Somalia (floods, epidemics) ; Sudan (viral haemor­ 3. 54 In collaboration with other agen­ rhagic fever). cies and organs of the United Nations, Afghanistan. Following devastating WHO provided health assistance to the floods, WHO assisted in re-estab­ national liberation movements recognized lishing the water supply and pro­ by the Organization of African Unity. vided US $6o ooo from the regular These included the Patriotic Front (Zim­ budget for the transport of drilling babwe), the South West Africa People's rigs and pumps. Organization (Namibia), the African Na­ tional Congress (South Africa), and the Cyprus. WHO collaborated with Pan Africanist Congress of Azania (South UNHCR in assisting the health Africa), which are struggling to maintain services of the country. A total acceptable levels of health and social of $1 528 810 was spent on the conditions in the most adverse circum­ health needs of displaced persons, stances. dispensaries for refugees, urgently needed medical supplies, control measures against the re-introduc­ 3·5 5 Support was continued to the multinational training centre at Morogoro, tion of malaria, and training of United Republic of Tanzania, for which technicians. WHO is executing agency, and which ~estern JDaclj?c Region prepares medical and allied personnel for service among the populations associated 3·5 3 Democratic Kampuchea (emer­ with recognized liberation movements. gency contingency plan); Fiji (cyclone); Philippines (influx of refugees, poliomyelitis 3. 56 Assistance was also given to the epidemic); * Tonga (cyclone); Viet Nam Palestine Liberation Organization in the (floods). recruitment of physicians and the provision * Details given at end of paragraph. of urgently needed medical supplies.

34 Chapter 4

Research Promotion and Development

4· I THE RESEARCH activities of countries imposed an obligation on head7 WHO, formerly carried out ex­ quarters to provide effective coordination clusively by headquarters, have and technical support at the different levels been reoriented to ensure substantial par­ of the Organization. It was also necessary ticipation by regions and countries. In­ at all times to keep an overall view of the creased emphasis has been placed on the scientific work being carried on in different strengthening of national research capa­ subjects and in different regions. The bilities and on the formulation, with the Programme Committee, in relation to active support of the regional advisory research funding, felt it necessary for WHO committees on medical research, of national to remain independent of donor agencies. and regional research priorities. The stress It also stressed the need to stimulate is on action-oriented field research and on further the exchange of research informa­ the need to relate research to health services ; tion through a variety of mechanisms. several WHO programmes, for example the As an important way of promoting co­ Special Programme of Research, Develop­ ordination, such research information ment and Research Training in Human should cover research policy, institutional Reproduction, the Special Programme for arrangements, and research resources , as Research and Training in Tropical Diseases, well as technical data and literature. and the Expanded Programme on Immu­ 4· 3 Special attention was paid by the nization, have considerable health services Programme Committee to the strengthening research components. of research capabilities. Constant mobili­ zation of human resources would be needed 4.2 The Programme Committee of the and a variety of means should be used to Executive Board in 1978 provided guidance achieve it, including the training of young on a number of important issues. It con­ workers from developing countries and sidered that WHO,. in partnership with national institutions, should in its research their active participation in research; the aim essentially at the solution of explicitly use of fellowships to promote health services research ; the promotion of career defined problems of public health im­ structures wherever needed ; and the in­ portance. It held that the integration of corporation of fresh talent into the Organi­ WHO's research activities into a coherent zation's pool of expertise. whole was essential. The assumption of greater responsibility and initiative by the 4·4 Finally, the Programme Committee WHO regional offices and in turn by stressed the desirability of designing a THE WORK OF WHO, 1978-1979

research plan and carrying out prospective sources. The subcommittee on informa­ studies related to health for all by the tion also encouraged institutions such as year zooo. Forecasts of health needs and the United States National Library of scientific developments were required that Medicine to offer increased assistance. took global, regional, and national factors For example, a quarterly bibliography of into account. Problems and appropriate tropical diseases is being compiled from research approaches should be carefully that library to meet the needs of the defined, and in that connexion the Advisory Special Programme for Research and Train­ Committee on Medical Research must ing in Tropical Diseases ; it goes to some provide leadership in establishing research 3700 individuals and institutions associated priorities that would help the Organization with the Special Programme. to attain its goal. 4·7 At the ACMR meeting in Novem­ 4· 5 In accordance with the Executive ber 1979, it was felt that the subcommittees Board's recommendations at its sixty­ on nutrition and on diarrhoeal diseases third session and the Thirty-second World had already completed their work. In Health Assembly's resolution WHA32. I 5, view of the successful catalytic role played a draft medium-term programme for re­ by such active but short-term groups, search promotion and development was additional subcommittees were proposed­ drawn up in line with the objectives on research administration, or career struc­ specified in WHO's Sixth General Pro­ tures in research, and on mental health gramme of Work (1978-1983). Within and allied neuropsychiatric problems in this general framework Member States developing countries. should find it possible to carry out health research in accordance with their own ~esearch training national priorities and determine the extent to which they wish for technical cooper­ 4.8 By enabling individual scientists ation. to obtain additional training, WHO re­ search training grants complement insti­ tution-strengthening. Emphasis is placed Global developments on postgraduate education, although grants are also awarded for training allied health, 4.6 The global Advisory Committee laboratory and support personnel from on Medical Research (ACMR) was active developing countries and, in some cases, in coordinating regional priorities and for training in management of research. synthesizing them into global initiatives. A wards are also made to promote the Following its June 1978 meeting, ACMR exchange of scientific knowledge by en­ subcommittees on health services research, abling investigators working on subjects nutrition, diarrhoeal diseases, and scientific of relevance to WHO programmes to information were established to review visit scientists in other countries working those aspects of research. The role of these in similar or related fields. subcommittees, particularly the first three, has been to work closely with WHO in 4·9 These two types of grant are starting or expanding research in their funded by the special programmes for respective areas. They gave valuable research and training as well as by the advice on programme development strategy regular budget. Well over zoo grants for and on the integration and harmonization research training, and over 5o grants to of contributions to research from different enable scientists to visit other institutions, RESEARCH PROMOTION AND DEVELOPMENT were funded by special programmes during goal-the attainment by all peoples of the the biennium. They are administered by world by the year 2ooo of a level of health headquarters, whereas those from the that will permit them to lead a socially regular budget and other sources are and economically productive life-and in normally handled by the regional offices. its review of the health situation throughout In general, grants are increasing in number the world highlighted the inadequate access as well as in the duration of the training of so many of them to any regular form of provided. Particular attention is given to health care. Among the health problems ensuring the relevance of the training to to which WHO drew attention were : regional and national health research pri­ - communicable diseases, in particular orities and to providing training within the need to make fuller use of existing the context of technical cooperation among vaccines but also to develop improved or developing countries. new vaccines, e.g., against parasitic diseases; United Nations scientific meetings - malnutrition, and the special needs 4.Io WHO took an active part in the of pregnant women and very young preparations for the United Nations Con­ children; ference on Science and Technology for - environmental diseases, and the par­ Development (Vienna, August I 979), which ticular importance of a clean water was preceded by a week-long colloquium supply; sponsored by the United Nations Advisory - family health/family planning, and Committee on the Application of Science the need not only for improved contra­ and Technology to Development. Among ceptive technology but also for better the problems reviewed were equitable access to services ; access to adequate energy and mineral - the provision of essential pharma­ resources, food and nutrition, population ceuticals that are both safe and low in issues, health care, poverty, illiteracy, cost, and the importance of making employment, and peace and security. Such greater use of traditional medicines ; problems cannot be solved by the efforts of one country or a small group of coun­ - the many psychosocial factors that tries ; the international scientific community have a bearing on health, and the need represented at the meeting showed aware­ for more skilled manpower and greater ness of their global nature and of the need utilization of community resources in to analyse comprehensively and systemati­ this area. cally the interdependence of sectors, coun­ 4· I 2 Indeed throughout, WHO empha­ tries, and regions. One expression of this sized the need in developing countries for awareness was the decision of I9 non­ more health manpower, the importance of governmental scientific and technological strengthening institutions, and the clear organizations to associate in order to under­ requirement for better career opportunities take a number of practical tasks defined by in health research. Stress was laid on the the colloquium. overriding need for technology that was 4· I I In its background paper for the appropriate, i.e., technically sound, cul­ Conference 1 WHO emphasized its ultimate turally acceptable, and available at an affordable cost. All these factors were in­ cluded in the primary health care approach. t Reprinted in WHO Chronicle, 33: 399-406 and 447-456 (1979). The obstacles were seen not only as tech-

37 THE WORK OF WHO, 1978--1979 nical, but also in terms of national political Region of the Americas will, community organization, and the effective collaboration of the world's 4.I6 The PAHO research programme scientific community. gave special attention to health services research, with particular emphasis on the need, to extend health services coverage. Regional developments Working groups were constituted to study the problems, and their conclusions were African Region presented to the health services research subcommittee of the global ACMR in 4· I 3 During the period covered by the June I979· present report, six Member States made a financial contribution to the special regional 4· I 7 Following the recommendations fund for medical research. of a working group, and in view of its importance in the Americas, amoebiasis 4· I4 After the second session of the was included in the programme on diar­ African ACMR, research priorities were rhoeal diseases. established for the major parasitic diseases, immunology, and health services research. 4· I 8 National and subregional meetings A network of 43 national and three regional were held to promote the definition of centres for research and training was set national policies in health research, in­ up and is being expanded. A regional cluding the study of present and future project for research grants and research coordination strategies, training, and the training grants became operational ; I4 ethical aspects of research. awards had been made up to September 4· I9 An inventory of human and ma­ I979· Workshops were organized to terial resources for health research was provide training in research methodology completed for all the countries of Central and to develop health research programme America except Nicaragua. Surveys are activities in the Region. A proposal was being carried out in Bolivia, Colombia, made to launch an Mrican health sciences Ecuador, Mexico, and Peru, and will soon publication and is being studied, but be started in Argentina, Brazil, Chile, and financial and language problems have been Venezuela. encountered. 4.20 Research training grants and me­ 4· I 5 The African ACMR at its third dical research grants were used to streng­ session (Zambia, November I978) recom­ then national research capabilities and to mended the establishment of a research assist young scientists both in their training promotion subcommittee to stimulate fur­ and in their reintegration on return to ther research within countries ; a health their home institution. Support was also services research study group that would given to enable scientists from developed give priority to primary health care ; and countries to carry out training programmes a study group to elaborate the regional in, and for the benefit of, developing component of the global diarrhoeal dis­ countries. ease control programme. The research promotion subcommittee was established 4· 2 I Special emphasis was given to the and visited ten countries in I979· The two inclusion of research and training pro­ study groups were also formed and will grammes in the curricula of postgraduate meet in I 980. studies in public health at universities in RESEARCH PROMOTION AND DEVELOPMENT

Brazil, Colombia, Costa Rica, Cuba, the and plans, including training and institu­ Dominican Republic, and Mexico. tion-strengthening.

4.22 Research in nutrition was carried 4· 2 5 By synthesizing the requirements out at the Institute of Nutrition of Central of countries the Regional Office was able America and Panama and the Caribbean to advance the programmes of health Food and Nutrition Institute ; in the services research, diarrhoeal disease control, zoonoses at the Pan American Foot-and­ and nutrition. The global programmes Mouth Disease Center and the Pan Ameri­ being developed in these areas accurately can Zoonoses Center ; in sanitary engineer­ reflect national and regional needs. ing, environmental health, and ecology at 4.26 The Regional Office collaborated the Pan American Center for Sanitary closely with the special programmes for Engineering and Environmental Sciences research and training in tropical diseases and the Pan American Center for Human and in human reproduction. Ecology and Health ; and in perinatology at the Latin American Center for Peri­ natology and Human Development. The European Region regional library, BIREME, expanded its 4.27 Health services research was the information network and disseminated in­ principal focus of research planning in the formation on a considerable scale. European Region. Within that research the European ACMR singled out five South-East Asia Region areas of high priority for promotion and development. They were broadly regarded 4.23 The fourth and fifth sessions of as distinct from, but complementary to, the South-East Asia ACMR were held in the acknowledged research needs of the April 1978 and 1979 in India and Thailand major programmes of the Regional Office respectively. The Committee reviewed the in the care of the elderly, cardiovascular progress of research, which is progres­ diseases, health manpower development, sively expanding to include almost all the mental health, nursing, promotion of priority areas it pinpointed at its first environmental health, and road traffic session in 1976. accidents. The five areas are: (a) standardi­ zation of methods, measurements, and 4.24 Following the Regional Com­ terminology in biomedical and health mittee's resolution at its twenty-ninth services research; (b) prevention, pro­ session, allocating 2.5% of the regional phylaxis, and early detection; (c) evaluation budget to research (a percentage that was of drugs and other therapeutic and diag­ matched with funds from the Director­ nostic substances ; (d) problems of health General's Development Programme), re­ care delivery; and (e) the economic aspects search activities were increased in 1978. of health care. This enabled the Regional Office to give further support to several research pro­ 4.28 A planning group was convened jects, to training in research through for each of these areas and subsequently structured courses, and to the schemes a consolidated report was prepared indicat­ for visits by scientists and research training ing the research problem and the action grants. The Regional Office promoted recommended. From the outset it was concerted efforts in Member States for the recognized as particularly important to development of research policies, priorities, achieve effective coordination with re-

39 THE WORK OF WHO, 1978--1979 search act1v1t1es in Member States, and its fourth in September I979· It reviewed mechanisms were developed to ensure that the progress in projects dealing with drug the priority areas singled out by the utilization, alternative approaches to re­ European ACMR were not merely in hydration, and traditional medicine. At harmony with but were also responsive the fourth session regional plans for applied to the scientific needs of countries in the research in nutrition and for field research Region. in malaria were also reviewed, together with the research component of the pro­ 4.29 Liaison was maintained through­ ject on the prevention and control of out with other groups active in medical water-associated diseases in the irrigation research and cooperation continued with schemes of the Gezira Province, Sudan. the European Medical Research Council. A meeting of European bodies concerned 4· 32 A workshop was held in Cairo with the subregional coordination of health in September I978 to establish detailed services research (September I979) reviewed plans for a regional orientation course in the possibilities of increased coordination health services research. The course itself of current and future health services re­ was held in January I979 in Alexandria, search and confirmed the need for active in collaboration with the Institute of coordination and liaison. National Planning, Cairo. The participants included three health professionals from 4.30 To ensure that research was each of six Member States in the Region. focused on a major health problem in The purpose of the course was to give Europe, it was decided to develop further guidance to the participants on the role initiatives around the common theme of of health service research in decision­ hypertension as related to health care. making and the formulation of health A review was made of the information policies, and to familiarize them with its available on I 3 5 hypertension research nature, objectives, and scope. The par­ studies in progress in the European ticipants were also given a short period of Region. Hypertension serves as a useful intensive field training in the use of health model for a variety of reasons, including services research methodology ; during the its link with other major chronic diseases course they prepared health services re­ found in the Region such as diabetes, search proposals for projects to be carried renal disease, ischaemic heart disease, out in their respective countries with atherosclerosis, and stroke. Moreover, WHO support. the wide range of factors influencing hypertension provide an opportunity to 4· 3 3 The Regional Office collaborated bring under consideration a number of with the Pakistan Medical Research Council health services aspects, e.g., evaluation of in organizing a health services research contributory and risk factors, screening workshop (Islamabad, April I979)· The and detection, clinical management of participants included mid-level to senior­ hypertensive disease, and cost/benefit level health administrators, medical analysis. teachers, and research workers.

Eastern Mediterranean Region 4·34 A study was planned in three countries of the Region to assess the 4· 3 I The Eastern Mediterranean ACMR effectiveness of the existing health care held its third session in March I978 and delivery system and initiate a process of RESEARCH PROMOTION AND DEVELOPMENT policy analysis and development, the object techniques ; diabetes in Polynesian and being ultimately to suggest changes that Micronesian islands ; the health hazards would lead to effective coverage of the of working populations, especially in con­ population by the year 2ooo. nexion with changing occupational environ­ ments ; vector control measures ; and the 4· 3 5 A regional scientific working methodology and planning of health ser­ group on liver diseases was formed and vices research. met in December 1979 to review work done so far in the Region on liver diseases 4· 38 National health authorities were and draw up plans for a regional research urged to develop self-reliance in research programme to study them. and questionnaires to ascertain the present position were completed for five coun­ Western Pacific Region tries in the Region. In two of the five 4.36 The strengthening of national re­ countries surveyed professional careers in search capabilities was one of the major full-time health research do not exist, preoccupations of the Western Pacific either for physicians or for other medical ACMR, which selected three institutes in scientists or technicians. In three of the three countries of the Region for initial five countries special incentives are given support. Research grants were awarded to full-time research workers in health or in relation to an interdisciplinary research biomedical sciences and, in those same programme on Schistosoma japonicum. A countries, there is legislative provision for wider coverage of WHO collaborating support to health and biomedical research. centres by discipline and by country was In some developing countries of the planned, and collaboration of centres among Region the conditions of service for themselves was encouraged. Preparations research workers have recently improved ; were also made to convene a working for instance, special salary scales for group of directors of national medical full-time research workers have been estab­ research councils. lished. * 4·37 Following the recommendations * * of the Western Pacific ACMR, a number 4·39 In summary, research promotion of subjects of research were promoted as and coordination activities during the part of WHO programmes of technical biennium focused on new processes as cooperation. They included research on well as on expanding the dimensions of clonorchiasis and paragonimiasis ; an inter­ WHO's involvement in research. A con­ disciplinary programme in a number of comitant quantitative growth was also countries on diarrhoeal disease control, apparent and is reflected in the reports with emphasis on the operational aspects on the individual technical programmes. of control measures ; and intervention Moreover national participation is clearly studies aimed at reducing the mortality becoming of increasing importance. Re­ and morbidity from acute respiratory search, and particularly the application of infections by at least 5o% by the year 2ooo. its results, will be among the decisive In addition, research was promoted on the factors in WHO's effort to attain health application of modern immunological for all by the year 2ooo.

41 Chapter J

Health Services Development

HE MOMENTUM given to and plans of action to implement that T health services development by Declaration. A major part of WHO's the Thirtieth World Health As- work in I 979 consisted in providing sup­ sembly in setting the social target of port for such formulation and, more im­ "Health for all by the year 2ooo" (resolu­ portantly, in ensuring that health services tion WHA30.43) was maintained by the at all levels responded to the challenges of International Conference on Primary the primary health care concept. Health Care held in Alma-Ata (USSR) in September I978. The Conference, which 5. 3 One of the principles inherent in was jointly sponsored by UNICEF and the Declaration of Alma-Ata is inter­ WHO, had been preceded by a number of sectoral collaboration. In order to provide national, regional and international meet­ the Director-General of WHO with relevant ings on primary health care so that it had advice in this area, it was decided to at its disposal not only the official docu­ establish a group which comprises some mentation but also reports on national twenty members from a broad range of experience, films relating to primary health disciplines, about one-half of them in care, and examples of appropriate health sectors other than health. The group will technology. ·It was attended by delegations meet during the second half of I98o. from I 34 governments and representatives of 67 organizations of the United Nations system and nongovernmental organizations 5·4 Many countries are re-examining in official relations with UNICEF or WHO. the adequacy of their mechanisms for The work of the Conference culminated in collaboration, both within the health sector the adoption of the Declaration of Alma­ and intersectoral (there are a variety of Ata, 1 the far-reaching implications of such mechanisms, some of them involving which are discussed in . the Introduction all the main development sectors at central to this volume. and other levels). WHO's support for this and other related processes in health

5.2 Among other things, the Con­ services development has been organized ference stressed the need to formulate in various ways. The most common national, regional and global strategies approach is to collect and analyse the experience of different countries in tackling problems that are common to them all. 1 Page v. Such analysis in I979 took the initial form HEALTH SERVICES DEVELOPMENT of studies carried out by nationals or by tions of the Alma-Ata Conference; nine national institutes, sometimes with finan­ countries participated in a workshop in cial support from WHO ; these were Yaounde (June 1979) to prepare a practical followed by consultations or workshops guide for students of health sciences ; a bringing together those responsible for multidisciplinary workshop was held in the studies and other experts. It is an Kintampo, Ghana (July 1978) based on the approach that promotes self-reliance and experience of the Brong-Ahafo rural in­ develops national capabilities for health tegrated development programme ; and a planning, implementation of programmes seminar on development, community parti­ and monitoring of results-prerequisites cipation, and training was organized in for any improvement in the health situ­ Dakar (July 1979). An interregional course ation. on nutrition (Ibadan, Nigeria, March 1979), particularly intended for teachers of pri­ 5. 5 A meeting of representatives of mary health care workers, was attended by nine countries and staff from all WHO 20 nationals from 14 countries; and a regions (Geneva, October 1979) discussed workshop for such teachers was organized the establishment of national health devel­ in Lome (June 1979). opment networks of institutes or centres as a mechanism for fostering national self­ 5.8 In the Region of the Americas, the reliance and capabilities or strengthening evaluation of the Ten-Year Health Plan such as already exist. Functions, organi­ for the Americas began in 1979 and the zation and financial support were examined findings will provide a basis for the for­ in the light of national experience. Plans mulation of national and regional strategies were proposed for action both by govern­ in primary health care. Emphasis during ments and by WHO, and for intercountry the biennium was on extension of health and interagency collaboration. coverage and on health systems based on the key policies of primary health care, intersectoral coordination, community par­ ticipation, and development of appro­ Primary health care priate technology. The operational ca­ pacity of health services is being expanded 5.6 The regional committees in 1978 in the context of integrated development, and 1979 devoted much time to reviewing which takes into account not only inter­ national and regional action in primary sectoral coordination but also the internal health care. National strategies and plans improvement of the health sector in terms of action will be presented to the 1980 of planning, programming, mobilization sessions, at which point the regional of resources, and management of oper­ strategies can be formulated. ations. In ten countries the community participation element was the object of 5. 7 In the African Region, there was extensive training and technical cooper­ a drive to popularize the concept of ations. In ten countries the community primary health care, highlight its social establishment of a training programme in and intersectoral nature, and provide ap­ community health for Central America and propriate training. Seminars and work­ Panama, based in Costa Rica. shops were held on specific aspects : a regional workshop in Botswana (De­ 5·9 In the South-East Asia Region a cember 1978) reviewed the recommenda- meeting (New Delhi, December I 978)

43 THE WORK OF WHO, 1978-1979

reviewed the recommendations of the improving the cost-effectiveness of health Alma-Ata Conference in the context of services by providing care at the lowest regional and national requirements. Four effective level, extending health education, of the ten countries in the Region-Ban­ examining the use of secondary and ter­ gladesh, Burma, India, and Thailand, which tiary level facilities and the recourse to between them have a population of some specialized personnel, strengthening re­ 8oo million-formulated countrywide pro­ search capabilities, developing information grammes and began to implement them. systems, and promoting awareness . in Other countries are either at the planning general. A number of projects were com­ stage or are experimenting with alternative pleted during the biennium, e.g., the study models to fit their political and socio­ on the health centre concept in Europe. economic situation. Nearly all countries The special health problems of local and started programmes for training com­ migrant populations in the Arctic were munity health workers. Stress is laid on examined by a working group (Septem­ making traditional medicine, widely used ber I979), which chose the areas for a throughout the Region, a part of primary study on comprehensive health services health care ; sectors other than health are in arctic and subarctic zones and defined increasingly being involved in the pro­ the approach to be adopted. motive and preparatory phases of such care. A joint UNICEF /WHO meeting on 5. I I In the Eastern Mediterranean Re­ the formulation of strategies for attaining gion, a significant trend can be discerned health for all by the year zooo (New Delhi, in the number of countries embarking on December I979) reviewed national health primary health care programming, imple­ policies and long-term plans with a view mentation and evaluation, accompanied to delineating the specific areas in which by intercountry collaboration. The period WHO would collaborate over the next two was marked by continued WHO support decades and defining the assistance it for the evaluation of primary health care should give in formulating strategies. programmes already in operation (Iran, Iraq, Libyan Arab Jamahiriya, Pakistan, Sudan, and Yemen) ; collaboration with 5.Io The programme of the European countries embarking on such programmes Region is mainly concerned with the (Democratic Yemen, Oman, and Somalia); relationship between medical and health care at community level, and in particular the setting up of a multidisciplinary re­ gional advisory panel on primary health with the part to be played by the community care (the first meeting was held in De­ in the adoption of the self-care concept cember I978, in Alexandria); and the and in the development of health services. preparation of a medium-term programme Most developing countries equate primary health care with front-line (first contact) for I978-I98 3· medical and health services, but the ap­ proach as practised in the industrialized 5.I2 In the Western Pacific Region countries is somewhat different and re­ primary health care was promoted by a quires an interpretation of the Declaration series of conferences and workshops. To of Alma-Ata that will fit the real situation. follow up the eight national seminars and Special emphasis is therefore being given the regional conference (Manila) in I977, to analysing the applicability and accepta­ an intercountry workshop on primary bility of self-care in the European context, health care development was held in

44 HEALTH SERVICES DEVELOPMENT

Malaysia and the Republic of Korea Appropriate technology for health (November/December I978), and resulted in research and development projects in 5·I4 The Health Assembly in I978 both countries. In the South Pacific a (resolution WHA3 I. 34) requested the Di­ conference on primary health care, includ­ rector-General "to intensify the involve­ ing diarrhoeal diseases control, was held ment of Member States in the further in Suva (August I979) and a national development of the global plan of action seminar took place in Kiribati 1 (Novem­ for the programme of appropriate tech­ ber I979)· The nursing aspect of primary nology for health" ; and in the same year health care and the role of allied health the Alma-Ata Conference recognized the personnel was emphasized, a national importance for primary health care of workshop on the subject being organized ide?tifying, developing, adapting and ap­ in the Republic of Korea. The use of plymg such technology. Particular atten­ health teams in rural work was the subject tion has therefore been given to clarifying of an interregional workshop, which in­ the concept of appropriate technology and cluded field visits (Tacloban, Philippines, its implications at country level for the October I979)· primary health care approach. Information on relevant techniques was disseminated ; periodic newsletters were issued ; and a

5. I 3 National and regional develop­ display of appropriate technology was ments were reinforced by a number of organized at WHO headquarters. interregional or global activities. The 5. I 5 Proper exchange of information UNICEF/WHO Joint Committee for on appropriate technology is essential, _Health Policy selected as the subject for and work was directed towards ascertain­ 1ts I979-I98o study: "Country decision­ ing what existing services, linked with making in the achievement of the objectives national information systems, could form of primary health care". Seven countries the basis for an international information (Algeria, Burma, Costa Rica, Democratic system. A possible structure for such a Yemen, Mali, Mozambique, and Papua New Guinea) discussed the operational system was discussed at a meeting (Manila, aspects of the studies to be undertaken November I979), the report of which puts forward alternative mechanisms for at a preparatory meeting in November I979· information exchange. A directory of Other activities included UNICEF/WHO organizations, institutions, groups and in­ workshops on primary health care for the dividuals concerned with appropriate tech­ joint training and orientation of senior staff; an interregional study on community nology was prepared, and efforts were health workers ; participation in the ACC made to ascertain their particular fields of interest with a view to assessing their Task Force on Rural Development ; and activities. 2 the development of new activities with a number of nongovernmental organizations, 5. I 6 In the African Region, after con­ e.g., the Intert\ational Organisation for tacts with institutions, agencies and re­ Cooperation in Health Care (Medicus search centres working in this area, several Mundi) and the International Council for suitable techniques were identified, relating, Adult Education.

2 ~pp~opri~t~ .tecknology for health. A directory of orgamzatzons, mstJtutzons, groups and individuals. December 1 Formerly Gilbert Islands. 1978 (WHO document ATH/78.z).

·45 THE WORK OF WHO, 1978-1979 for example, to water quality control ; local production and distribution of oral water catchment, distribution and purifi­ rehydration salts (a manual for use by cation ; waste disposal ; food and nutrition ; countries is in preparation); small-scale and vector control. production of essential drugs ; and basic equipment for peripheral health labora­ 5. I 7 Information on appropriate tech­ tories. nology was disseminated throughout the South-East Asia Region, and many new 5. 2 I The search for appropriate tech­ techniques were developed : for example, nology where a need was known to exist the practical administration of oral re­ included: the testing of re-usable plastic hydration in rural homes was simplified syringes, of portable refrigeration equip­ by the development of a special spoon for ment, and of pressure-cookers that could measuring the required proportions of salt be used by front-line services for steriliza­ and sugar. tion purposes ; the field testing of poly­ (vinyl chloride) well-screens in the Philip­ 5. I 8 In European countries, the prob­ pines ; and the production of health lems are somewhat different: they relate educational material for illiterate popu­ to the indiscriminate application of a lations in Mexico. The provision of low­ whole range of sophisticated technologies cost spectacles for developing countries that are at the disposal of the health care is under consideration and studies will system. The need therefore is to select be carried out in Pakistan and Sudan as a reasonable number of techniques and from I98o. define the types of equipment that are appropriate for the health needs of the 5.22 All these activities entailed col­ community in question. laboration with other organizations, both intergovernmental and nongovernmental ; 5. I 9 Two regions-the Eastern Medi­ for example, UNICEF was involved in terranean and the Americas-were parti­ many aspects of the programme, in par­ cularly concerned with the maintenance ticular in connexion with equipment for and repair of equipment and organized primary health care. The lists of equipment countrywide maintenance programmes and for peripheral services are being con­ the training of hundreds of national tech­ stantly evaluated and revised. nicians and managers. In the Eastern Mediterranean Region ad hoc or long-term training was undertaken in Afghanistan, Democratic Yemen, Jordan, Pakistan, Disability prevention, rehabilitation, and Somalia, and Yemen. The regional training health care of the elderly centre for the maintenance and repair of medical equipment in Cyprus was in oper­ 5. 2 3 The emphasis in this programme ation and a similar centre in Baghdad was is on rehabilitation technology and on the expected soon to begin its work. community approach a~ distinct from institutional services. It has been estimated 5. 20 A series of meetings at head­ that there are 6o million people in the world quarters or elsewhere-in which inter­ who could be helped to a better life by national and national experts, as well as improvement of their functional capacity, representatives of UNICEF, UNIDO and by educational and vocational measures, FAO, took part-covered such aspects as or at least by a better understanding of

46 HEALTH SERVICES DEVELOPMENT their problems and a wider acceptance by accidents and information is being col­ the community. lected. Participants from eight countries attended the third postgraduate course on 5.24 Some 40 million disabled people traffic medicine (Paris, December 1978). live in developing countries, and very few of them have access to any services at all. 5.26 In the Region of the Americas, To facilitate the provision of such services, steps were taken by various countries to a manual on community training for the promote effective community measures for disabled has been drafted. It contains the prevention of disability and provide guidance on training that can be carried simple community rehabilitation services. out by members of the disabled person's In Mexico the health authorities set up a family with minimum supervision by field study in and around Toluca, which primary health care workers, and describes has the necessary health services including the measures to be taken by local teachers a rehabilitation centre. Community health and community leaders. Testing of the workers were taught to identify the manual began in 1979 in Botswana and disabled persons in the community, evalu­ Mexico ; seven other countries asked for ate their disabilities, and prescribe simple WHO cooperation in introducing and rehabilitative activities. A meeting of evaluating it ; and a meeting of repre­ therapists carrying out English-language sentatives of the national institutes taking training programmes in the Caribbean part in the tests was held in Mexico City (Nassau, October 1978) recommended that (November 1979). The manual should a similar study should be made in one of prove an inexpensive but effective way of the English-speaking Caribbean islands. meeting the need for rehabilitation services at community level. Feasibility studies and 5.27 In the South-East Asia Region, the final evaluation of its contents are community surveys were sponsored in planned for 1981, the International Year India and Indonesia to assess the magnitude for Disabled Persons. of the problem and ascertain patterns of disability. Services for rehabilitation of the 5.25 In the African Region, the interest disabled were promoted through an inter­ in disability prevention and rehabilitation country seminar (Solo, Indonesia, 1978) has increased. WHO collaborated in at which the present position was reviewed establishing orthopaedic workshops in four and medium-term programmes formulated countries (Benin, Guinea-Bissau, Ivory for each country and for the Region. Coast, and Upper Volta) ; and participants Community-oriented services were pro­ from ten countries (Benin, Congo, Gambia, moted through technical collaboration in Ghana, Lesotho, Mali, Rwanda, Swaziland, nearly all countries of the Region. To meet Upper Volta and Zaire) attended the third the demand for orthotic and prosthetic African training course for prosthetic and appliances, appropriate technology utiliz­ orthotic technicians organized by the World ing local materials was promoted. National Rehabilitation Fund (Nairobi, 1978). The and regional training facilities in com­ possibility was examined in 1979 of training munity-oriented disability prevention and multipurpose rehabilitation workers in Mali rehabilitation for health and allied personnel and establishing provincial centres for were strengthened. orthopaedics and rehabilitation. Many countries of the African Region are con­ 5.28 The disability prevention pro­ cerned at the high number of traffic gramme in the European Region is closely

47 THE WORK OF WHO, 1978--1979 linked to health care of the elderly and of primary health care techniques in prevention of road traffic accidents. Five disability prevention and in rehabilitation. ad hoc technical groups were set up to Several Member States collaborated in a study inter alia services and systems of care survey designed to further the introduction for the elderly and disability prevention, of meaningful programmes for care of the including screening. An interregional aged. In the prevention of road traffic planning and coordinating committee met accidents, a special multidisciplinary com­ in I979 to discuss the global programme mittee was established in recognition of for health care of the elderly, for which the multiple causes of such accidents. the Regional Office is the focal point. Work will concentrate on development of It is also the focal point for the global an accurate information system, elucida­ programme on prevention of road traffic tion of the human factor in traffic accidents, accidents, and has oriented the European and establishment of emergency care programme in this area so as to permit the facilities. participation of other regions and provide a model for global activities. Technical 5.30 A rehabilitation programme is groups were convened on (I) road accident being developed in the Western Pacific statistics (with special emphasis on record­ Region. WHO is participating in the ing of morbidity and disability) ; 1 (z) the Philippines in a comprehensive national influence of alcohol and drugs on driving ; programme beginning with a survey of and (3) medical monitoring of road acci­ physically disabled persons. The regional dents. (See also Chapter I 5, paragraphs programme for care of the aged is still J5 . I I 0 and I 5. I I I). at an early stage, since the extent of the problem must be determined before a 5.29 In the Eastern Mediterranean Re­ realistic programme can be formulated. gion, the emphasis was on building up A regional programme on prevention of the infrastructure, both by training and road traffic accidents was, however, estab­ by procurement of equipment and supplies. lished in I978, the first step being the The establishment of rehabilitation services collection of information from all countries was promoted in eight countries-Afghan­ of the Region on the incidence and severity istan, Iraq, Jordan, Lebanon, Saudi Arabia, of such accidents and the resources being Somalia, Sudan, and the Syrian Arab devoted to road safety programmes. A Republic. In Jordan, WHO gave its working group (October I979) developed support to a study on consanguineous guidelines and made recommendations for marriages-the present rate of such mar­ policies, strategies and methods of inter­ riages, the trends over a period, and the vention. implications for health, especially the risk of disability. A project to introduce a community programme for the control of Health services planning and cerebral palsy was started in collaboration management with the Queen Alia Welfare Fund and the Ministry of Health. Throughout the 5. 3 I In the comprehensive study of the Region, stress was laid on the introduction planning, programming, design and archi­ tecture of hospitals and other health care facilities in developing countries, started 1 World Health Organization. Road traffic accident statistics. Report on a WHO Ad Hoc Technical Group. in I974, another volume was published of Copenhagen, 1979 (EURO Reports and Studies, No. 19). Approaches to Planning and Design of Health HEALTH SERVICES DEVELOPMENT

Care Facilities in Developing Areas. 1 An developing countries was organized (Ma­ evaluation of health care facilities was made nila, 1978), which, inter alia, gave attention in the field by way of case studies in to health care facilities. Algeria, Senegal, Sudan, and Zambia. These were national studies supported by 5. 3 3 In I 979 new activities were intro­ WHO and intended to ensure that the duced to help countries in gearing their planning and operation of health care national health systems to the support of facilities are increasingly relevant to local primary health care by ascertaining tech­ needs and take into account local possi­ nical requirements and organizing the bilities. The programme encompasses not exchange of experience. Two international only the health care system (especially at courses, in English, were held on the local level) of which the facilities are a planning, organization and management of component, but also health management, health care delivery in support of primary which conditions the proper use of the health care (Sofia, 1978 and 1979); these facilities. The report of the first study, followed earlier courses on the subject which took place in Sudan, was finalized in French. and approved by the Government at an intersectoral meeting (Khartoum, Decem­ 5. 34 In the African Region, workshops ber 1979). were organized on health services planning and management for both national and 5. 32 The need for linking subjects too WHO staff (United Republic of Cameroon, often compartmentalized was also felt at 1978 and 1979). In the Western Pacific regional level. In the Eastern Mediter­ Region, WHO collaborated with the Philip­ ranean Region, situation analyses on plan­ pines in the restructuring of its health care ning, design, construction, equipment and delivery system ; with the Republic of management of hospitals and other health Korea in the development of its basic care facilities were prepared in a number health services, particularly with regard to of countries and will eventually lead to a allocation of resources as between hospital comprehensive regional programme in this services and general services ; with the field. In the Western Pacific Region, a Lao People's Democratic Republic in the complex intercountry project was in oper­ development of a rural health care system ; ation to provide training for national staff and with Papua New Guinea in designing of the collaborating countries in hospital a primary health care system linked to administration (at the University of the health services, as part of the integrated Philippines) ; in maintenance and repair of health services and health manpower de­ medical equipment (at the Central Institute velopment project in that country. China of Technology, Upper Hutt, New Zealand); was host to several study tours on various and in design of health care facilities (at the innovative aspects of primary health care, College of Architecture, University of the including the integration of traditional Philippines). In collaboration with the medicine into health services and the International Hospital Federation, a re­ fostering of community responsibility. gional conference on health services in 5. 3 5 A study group was held in Geneva 1 World Health Organization. Approaches to planning (October 1979) on the measurement of and design of health care facilities in developing areas, coverage, effectiveness and efficiency of Volume 3· Geneva, 1979 (Offset Publication No. 45). various patterns of health care. The Volumes I and 2 were published as Offset Publications No, 29 and No. 37, in 1976 and 1977 respectively. experience of Burma, Costa Rica, Egypt,

49 THE WORK OF WHO, 1978-1979

Finland, Malaysia, Nigeria, the Republic cion, special emphasis was given to the of Korea, and Senegal was discussed and organization of efficient emergency medical recommendations were made for continuing services. In the Eastern Mediterranean the study, which aims at developing Region, a regional advisory committee on material that will help countries to monitor emergency medical services was set up. progress in primary health care. The group emphasized the importance of decision­ 5. 38 Work on the economic aspects of makers and managers using such data as health services was intensified. The Executive an aid to assessing policy objectives, Board at its sixty-third session (1979) namely equitable provision of coverage, considered at length the recommendations improved allocation of resources, and of the WHO Study Group on Financing community participation. of Health Services.1 An interregional seminar on the same subject for senior 5.36 To promote the use of epidemioloo health administrators (Mexico, 1979), in as a tool in health care administration, which 26 countries took part, discussed particularly for the peripheral health ser­ the suitability of a draft manual to guide vices, a WHO-sponsored study was in­ surveys of health sector financing. Manuals itiated, with the participation of Botswana, and monographs on this ·subject were Burma, Ecuador, Iran, Malaysia, Niger, prepared in the Region of the Americas. and Thailand. Following a preliminary WHO and CIOMS jointly organized an meeting of national health managers international conference on economics and (Geneva, March 1979), these countries are health policy (Geneva, November 1979). now sifting their experience with a view The American Public Health Association, to its exchange within the context of in cooperation with WHO and certain technical cooperation among developing nongovernmental organizations, ran a countries. There is a clear trend towards workshop on health care financing in providing an epidemiological basis for the Latin America (Colombia, April 1979) ; practical day-to-day activities of primary and a consultation of countries of the health care, i.e., shifting epidemiology South-East Asia Region was held on the from the predominantly central position same subject (New Delhi, July 1979). it has hitherto occupied and employing its methods more directly in primary health 5. 39 The Regional Office for the care. Americas was particularly concerned with the additional resources that could be 5. 37 An interregional seminar on enter­ obtained for health work : among the genry care in natural disasters was organized action taken was assistance. to countries (Manila, 1978) in collaboration with in preparing requests for loans. Inter­ UNDRO and various organizations (see national organizations-especially those of Chapter 3, paragraph 3. 38) ; it was well the United Nations and inter-American attended by participants from disaster­ systems-have intensified their technical prone areas. In the Region of the Americas, cooperation programmes and increased the a programme explicitly directed towards financial resources available for them : an emergency and ambulatory health services was established, to meet increasing demands estimated US$ 2 5 million for technical for such services. In the European Region, cooperation, and some US$ 500 million in the context of the programmes on road traffic accidents and on disability preven- 1 WHO Technical Report Series, No. 625, 1978 •. HEALTH SERVICES DEVELOPMENT for construction of physical infrastructures, 5·43 At the end of 1979, WHO was was spent or allocated throughout the collaborating in more than two hundred Region during 1978 and 1979· cases in substantive health services re­ search, or in activities in support of 5.40 In the Western Pacific Region research, at various stages of development studies of unit costs or cost-effectiveness in 94 countries. Such collaboration is a analysis were carried out for different parts part of WHO's technical programmes and of the health services in Papua New Guinea, is described under the relevant headings the Philippines, and the Republic of Korea. in this report.

5·44 The African ACMR at its third Health services research session (N'dola, Zambia, November 1978) recommended that Member States should 5·4 1 Health services research has re­ promote national activities in this area by ceived particular emphasis during the past setting up working groups to study specific few years, as evidenced by the resolutions aspects, giving priority to training of of the Health Assembly, the Executive health services research workers, and ensur­ Board, and the regional committees, 1 and ing appropriate information support. Three by various recommendations of the global institutions-in Ghana, the United Repub­ and regional advisory committees on lic of Cameroon, and the United Republic medical research. Moreover the Alma-Ata of Tanzania-were chosen for collabor­ Conference specifically referred to the need ation in health services research. for health services research and operational studies (recommendation 16 of its report). 5·4 5 In the Region of the Americas, A subcommittee on health services re­ the regional ACMR (Lima, May 1978) search, established by the global Advisory recommended the establishment of working Committee on Medical Research (ACMR) groups to examine definitions and methods in May 1978, met four times during the of health services research. Meetings to biennium (in Geneva, Alexandria and promote the concept were held in Bolivia, Washington) and is trying to mobilize Costa Rica, and Mexico and were planned financial support for health services re­ for Argentina and Brazil. Steps were taken search in various countries. to establish contact with other groups concerned with health services research, 5.42 By June 1978 all six regional to promote the methods of such research, advisory committees on medical research and to give direct support to certain studies had considered the matter. Negotiations in progress. The latter concern mainly were in progress for the establishment of the extension of health services coverage, collaborating centres in Colombia, Cuba, the financing of health services, hospital Egypt, Iran, Mexico, and the United engineering, maintenance of equipment, Kingdom, while in the Republic of Korea and appropriate technology. a collaborating centre was designated in which the main emphasis would be on 5.46 In the South-East Asia Region, health services research. priority was given to research on alternative strategies for health care delivery, with emphasis on primary health care. A study 1 Resolutions EBS7.R32, WHA30.40, WHAp.IS, AFR/ group convened by the Regional Director RC2S/R6, SEA/RC30/RS, SEA/RC3I/R4, WPR/RC2S/RIO and WPR/RC28/RIS. held three meetings (New Delhi, 1977 THE WORK OF WHO, 1978-1979 and I978) and identified specific research making (Alexandria, January I979) ; a priorities, which were endorsed by the national workshop (Islamabad, April I979) regional ACMR and led to a variety of had similar objectives. research and related activities at country and intercountry level. A regional meeting 5·49 In the Western Pacific Region, on the development of health services the task force on health services research research (New Delhi, November I979) at its third meeting (Manila, August I978) brought together senior executives in the was composed of representatives of seven health sector and staff from development countries (Australia, Japan, Malaysia, New centres and academic institutions. Zealand, Papua New Guinea, the Philip­ pines, and the Republic of Korea). It 5·47 The European ACMR set up formulated a regional programme, and working groups to consider the following detailed strategies, tactics, and methods priority areas : (I) standardization of meth­ for planning of health services research ods and measurements in biomedical and at country level. Research on the health health services research ; ( 2) prevention, services in Malaysia, the Philippines, and prophylaxis and early detection of diseases ; the Republic of Korea led to changes in (3) evaluation of drugs and other thera­ the general health services of those coun­ peutic or diagnostic substances ; (4) prob­ tries ; the Korea Health Development lems of health care delivery ; and (5) Institute was designated a collaborating economic aspects of health care. Its action centre for health services development in was strongly endorsed by the Regional I979 and a plan of future activities was Committee in September I978, which prepared. The task force held a fourth especially stressed the need for a better meeting during the biennium (Manila, understanding of health services research, July I979) to consider the results of the for more resources to be devoted to it, second session of the global ACMR sub­ and for the collaborating research estab­ committee on health services research. lishments to be chosen bearing in mind the interdisciplinary nature of the research. Traditional medicine At its fourth session (October I978), the European ACMR proposed two priority 5.50 During I978-I979 traditional subjects : hypertension, 1 and economic medicine became an important element in aspects of health development. the strategy for attaining health for all by the year 2ooo. In particular, the Alma-Ata 5.48 In the Eastern Mediterranean the Conference recognized the role of practi­ regional ACMR and an interministerial tioners of traditional medicine in primary consultation on health services and man­ health care teams at community level, as power development both placed great evidenced by Article VII of the Declaration emphasis on health services research as a of Alma-Ata. Moreover it became apparent way towards comprehensive health ser­ during the biennium that interest in tra­ vices in the countries of the Region. ditional medicine was not confined to the An orientation course was held to fam­ developing countries or to African and iliarize health administrators and research Asian cultures in particular but was workers with the part that can be played worldwide. by health services research in decision- 5. 5I A global programme was therefore 1 See also Chapter 4, paragraph 4·30. instituted which, although coordinated in HEALTH SERVICES DEVELOPMENT

Geneva, is implemented at regional or 5·54 A number of meetings, consul­ country level in accordance with the wishes tations and seminars were held in 1978-1979 of individual governments. In 1979 the that brought together experts from many Executive Board (resolution EB63.R4) re­ disciplines-not only from systems of quested the Director-General to intensify traditional medicine such as Ayurveda, the development and implementation of the Unani and traditional Chinese medicine, programme by way of a more realistic and but also from medical specialties such as flexible approach to traditional medicine cancer, diabetes, cardiovascular diseases through health care programmes adapted and pharmacology and from such sciences to different socioeconomic conditions. as biology, botany, sociology, and anthro­ pology ; they came from all regions and 5. 5z Many governments are now re­ from other organizations of the United viewing their traditional and indigenous Nations system. health care resources, recognizing the potential that these represent in terms of 5• 5 5 A consultation on the potential manpower and other health services com­ for cancer therapy of plants indicated by ponents. Some are giving serious con­ traditional medicine was held in 1978, and sideration to integrating traditional medi­ there was a similar consultation in 1979 cine into their national health services and on the treatment of diabetes and cardio­ are examining their health legislation with vascular diseases by such plants. It was a view to rev1s1on. Governments where agreed that the active participation of traditional medicine is already part of the practitioners of traditional medicine in the national health system are able to provide health services would require appropriate technical cooperation at country level to and effective lines of communication ; and other countries interested in following that task forces should be established to their example. The study tours conducted provide WHO with the necessary expertise in China for this purpose (see para­ when developing guidelines for such pro­ graph 5. 58 below) attracted not only grammes. WHO should encourage collab­ participants from developing countries but orative research on the development, also from the economically developed evaluation and utilization of plants in the countries because of the interest aroused, treatment of disease ; pharmacological for example, by medicinal plant therapy, 1 principles should be adhered to when production of plant extracts, and the use evaluating the efficacy of medicinal plants ; of acupuncture for specific disease therapy the WHO project to acquire, catalogue and for analgesia. Those countries have and make available information on the also expressed interest in the anthropolo­ plants used in traditional medicine should gical, cultural and psychosocial aspects of be expanded ; meetings should be encour­ traditional medicine and in providing aged between practitioners of traditional facilities for research training and studies. medicine and scientists involved in re­ 5• 5 3 There is no doubt that the growing search on such plants ; a dialogue at recognition of systems of traditional medi­ national level between traditional healers cine is mainly due to the fact that they are and health professionals should be insti­ a logical and cost-effective way of ensuring tuted as soon as possible ; traditional health care at the grass-roots level and that medical practices of proven value should they use locally available resources. be introduced into the curricula of medical students, nurses, pharmacists, health auxil­ 1 See also Chapter 8, paragraph 8.16. iaries, and other health workers ; and THE WORK OF WHO, 1978-1979

WHO should provide information to in Accra in 1980. Their purpose is to developing countries on the research being evaluate the experience of practitioners of carried out in these areas in both developing both traditional and modern medicine in and developed countries. a number of African countries, with a view to evolving strategies and approaches for 5• 56 A meeting on research and training close collaboration between the two in traditional systems of medicine in systems. developing countries, with particular refer­ ence to medicinal plants and herbs, was 5.6o In the Region of the Americas organized jointly with the Istituto Italo­ traditional medicine has been studied for Africano (Rome, April 1979). many years, and recently Member States have shown an increased interest in its 5. 57 At the first International Con­ potential for extending health services ference on Traditional Asian Medicine coverage. An agreement was made between (Canberra, September 1979), which was the Inter-American Indian Institute and cosponsored by WHO, it was recognized PAHOJWHO for the study of traditional that, for traditional medicine to make medical practices in the Andean countries ; further advances, western-trained doctors, work started in 1979 and a report was scientists, and traditional healers must pool submitted to the Fifth Meeting of Health their knowledge in the interests of an Ministers of the Andean Group. Consider­ integrated health system ; such integra­ able research on medicinal plants is being tion is already being examined by WHO. undertaken in Mexico. P AHO JWHO also 5. 58 Study tours on traditional medi­ took part in a comparative study of cine took place in China in 1978 and 1979, institutional and traditional medicine in for participants from all regions ; courses the coastal and mountainous regions of were given in both English and French. Ecuador, in which the characteristics, An interregional seminar on the use of content and techniques of traditional medi­ acupuncture and acupuncture anaesthesia cine were analysed and data collected on was also held in China (June 1979). the population served, the cost, and the results obtained. The Organization assisted 5. 59 Participants from the African Re­ in the updating and publishing of a biblio­ gion attended a three-month course on graphy on the practice of traditional medi­ acupuncture (1978) and took part in the cine in all the countries of the hemisphere. study tours in China mentioned above. Two such participants took part in a 5.61 Traditional medicine plays a sig­ consultation on acupuncture, moxibustion nificant role in the South-East Asia Region, and acupuncture anaesthesia, also in China where in many countries it is the only (1979). Support was given to the fourth type of health care for a large part of the conference on postgraduate studies in population and is legally recognized as central Africa and Mauritius (Libreville, such in some countries. A recent study June 1979), which reviewed traditional in a number of countries concluded that medicine, its pharmacopoeia, and the prob­ training programmes in Ayurveda, Unani, lems of integrating traditional and modern etc., could be improved, and that refresher medicine. Thanks to DANIDA's financial courses, including training in preventive support, an intercountry workshop was and social medicine, should be organized organized in Bamako (1979) and prepara­ for practitioners of these systems. Further tions were made for a second, to be held research was needed on traditional medi- HEALTH SERVICES DEVELOPMENT cinal formulas to ensure greater efficacy tioners and traditional healers, representa­ and standardization. WHO continued to tives of several other fields-pharmaco­ give support to a research study on the logists, sociologists, nurses, midwives, and efficacy of ayurvedic treatment of rheuma­ acupuncturists. toid arthritis made by the Ayurvedic Trust and Research Institute, Coimbatore, 5.66 There is very little literature on under the aegis of the Indian Council of the administrative aspects of traditional medi­ Medical Research ; the study will be cine as related to official he~lth services. evaluated in I98o. To bridge the gap, a handbook for use by health administrators and health workers 5.6z The Eastern Mediterranean re­ is being designed. It will outline the main gional Advisory Committee on Medical systems of traditional medicine, describe Research initiated a research pro­ the position in selected countries, review gramme in traditional medicine. A ques­ legislation in force, and suggest procedures tionnaire for the collection of baseline for the extension of health services coverage information was sent to research workers by a fuller use of traditional healers and and health authorities and the replies are indigenous health care systems. being analysed. On the basis of the findings a programme for the effective utilization of the resources of traditional Workers' health medicine in the extension of health care will be developed. 5.67 WHO's work in occupational 5.6 3 In the Western Pacific Region, health, in its new orientation, emphasizes a consultant requested by the Government three main areas : (I) providing health of Kiribati 1 classified and documented the care for underserved working populations ; medicinal plants used in that country, (z) establishing practical guides and stan­ reviewed the practice of traditional Kiribati dards for the assessment and control of medicine, and made recommendations on specific problems encountered at the place further research and on the role of tradi­ of work; and (3) coordinating occupa­ tional medicine in the health care system. tional health programmes with those of the general health and labour services. 5.64 Two WHO collaborating centres Technical cooperation with count-ries in­ were established in I979-at the Istituto creased rapidly during the biennium, when Italo-Africano, Rome, and at the Gujarat WHO provided services in various fields Ayurvedic University, Jamnagar, India. of occupational health to some twenty Recommendations were made for collab­ countries in all regions. orating centres to be designated in China on traditional medicine, medicinal plants, 5.68 Workers in agriculture and small­ acupuncture, and acupuncture anaesthesia. scale industries constitute the overwhelming Negotiations were also under way at the majority of the productive manpower, end of I979 for centres in Africa, the particularly in developing countries, but Americas and the Eastern Mediterranean. occupational health services , for these 5.6 5 In I 979 a WHO expert advisory groups are often inadequate, or even panel on traditional medicine was established, nonexistent. During the biennium WHO comprising, in addition to medical practi- conducted a series of field studies on the health problems encountered in these 1 Formerly Gilbert Islands. sectors, undertook the preparation of THE WORK OF WHO, 1978-1979 guidelines for the organization of appro­ 5.71 In the African Region, WHO priate occupational health care, and con­ assisted Ghana, the Ivory Coast, and vened or participated in various meetings Zambia in a national evaluation of their on the subject. Field investigations in occupational health problems and services Sudan continued in 1979 and further with a view to developing regional re­ investigations were started in Burma, the search and training centres. Philippines, and the United Republic of Tanzania. In collaboration with UNEP, assistance was provided to the Govern­ 5. 72 In the Region of the Americas, ment of Egypt for the development and activities were directed towards increasing coordination of occupational health ser­ national capabilities in occupational hy­ vices, particularly for workers in agri­ giene, developing control programmes culture, where a major hazard is poisoning suitable for small-scale industries, and by pesticides. In Indonesia, a UNDP JWHO reducing both accident rates and cases of project on similar lines included advisory exposure to toxic chemicals in agriculture. services on agricultural hygiene. A work­ shop on occupational health care in agri­ 5·73 In the South-East Asia Region, culture (November 1979) produced the a UNDP-assisted project for the strength­ first of a series of guidelines for the develop­ ening of health services in newly indus­ ment of services in this sector. It is recog­ trialized areas became operational in Burma nized, however, that much more work by in 1979 ; its main purpose is to provide WHO in relation to agriculture and small­ integrated basic health services for workers scale industries is required. and their families and to strengthen health care coverage of the surrounding popu­ 5.69 The health problems of migrant lation. In Bangladesh, support was given 1vorkers were studied in the African Region to the National Institute of Preventive (1978), in Botswana, Lesotho, Mozambique, and Social Medicine, Dacca, in setting up and Upper Volta, to evaluate the degree an industrial health laboratory. An inter­ of risk to the health and safety of workers ministerial coordinating committee was taking up employment in the more in­ formed on which the ministries of health, dustrialized countries of the Region with labour, social welfare and industry are a view to recommending control measures. represented. Similar assistance is being WHO also organized a series of meetings given under a joint DANIDAJILOJWHO in 1978 and 1979 on health education of project in Sri Lanka. migrant workers, particularly directed to the recognition and control of adverse psychosocial factors at the place of work. 5·74 The Regional Office for Europe cooperated with Denmark and Poland in 5. 70 The development of occupational developing their institutes of occupational health services and institutions and their health and in training staff in industrial coordination or integration with national toxicology ; with Portugal and Spain in health services is a growing programme. improving occupational health services by In addition to the various projects referred way of epidemiological studies and in­ to above, WHO collaborated with coun­ tensified training ; and with Greece in tries in reviewing their occupational health studying the establishment of a national systems, in strengthening preventive meas­ institute for occupational health attached ures, and in training personnel. to the Ministry of Social Services. HEALTH SERVICES DEVELOPMENT

5·75 In the Eastern Mediterranean Re­ 5. 78 A new programme was started to gion plans were drawn up with Egypt, establish simplified methods of air analysis, Jordan, Pakistan, Qatar, and Yemen for in which WHO coordinates the work of the national centres in occupational health a network of collaborating centres in which it is intended should be established Brazil, Bulgaria, Czechoslovakia, Egypt, in all countries of the Region. A joint and Switzerland that are testing analytical ILOJWHO multidisciplinary team visited methods for selected pollutants in the Iraq in I978 to study and advise on various working environment. Guidelines on matters of occupational health and safety. the evaluation of gases and vapours in the working environment were produced 5.76 In the Western Pacific Region, in I 979, and work on the evaluation of a long-term project in occupational health particulate matter has begun. in Malaysia led to the organization of a national interagency committee to coordi­ 5. 79 The programme on methods for nate activities relating to workers' health ; the ear!J detection of health impairment in a series of surveys was conducted to obtain occupational exposure to health hazards basic data, and a national centre for began in I976, and in I979, following training and research is being established. various scientific meetings, a document was WHO helped the Philippines to strengthen compiled on such early detection in relation the Division of Occupational Health in to selected organic solvents and metals the Ministry of Health and to organize (benzene, carbon tetrachloride, ketones, training courses for occupational phy­ trichloroethylene, xylene, cadmium, lead, sicians and nurses. Preliminary studies manganese and mercury). It summarizes on occupational health services were made present knowledge on the early signs of in Fiji, the Republic of Korea, and Tonga. occupational disease caused by these sub­ stances and the corresponding diagnostic 5. 77 In its work on guidelines and procedures. standards WHO has for several years been studying the methods used in various parts 5.8o Respiratory diseases due to the of the world to recommend exposure inhalation of vegetable and other organic dusts limits for occupational hazards, and the are among the most commonly encountered first study group on this subject (I 979) occupational diseases in developing coun­ recommended health-based permissible tries. WHO organized two meetings limits for the commonly encountered heavy during the biennium to review the epi­ metals-cadmium, lead, manganese and demiology of occupational exposure to mercury-that constitute serious occupa­ these dusts, and draft guidelines for early tional risks. 1 The aim is to harmonize detection and control. This is the beginning the standards set by institutions in differ­ of a long-term programme to explore the ent countries, which have hitherto varied various health hazards represented by the considerably. This programme is carried wide variety of dusts encountered in out with the cooperation of the National agriculture and in the textile industry Institute for Occupational Safety and throughout the world. Health, United States of America. 5. 8 I As part of interagenry coordination in occupational health work, UNEP con­ 1 Recommended health-based limits in occupational exposure vened three meetings during the biennium to heavy metals. Report of a WHO stut!J group (to be published in the WHO Technical Report Series). with a view to instituting a global pro- THE WORK OF WHO, 1978-1979 gramme on the improvement of the work­ new orientation of WHO's programme for ing environment, to be carried out by ILO, workers' health in the coming years. It UNIDO, WHO, and other specialized emphasized the need for strengthening agencies. WHO and ILO are reviewing coordination with other organizations in the their present Memorandum of Under­ United Nations system, particularly ILO, standing, which dates back to 1954, and are and for effective technical collaboration intensifying their cooperation in occu­ with Member States in setting occupational pational health matters. In 1979 the Health health standards and guidelines. The Assembly (resolution WHA32.14) requested meeting of a working group (November the Director-General to prepare a pro­ 1979) was the first step in elaborating such gramme of action that would embody the a programme. Chapter 6

F ami!J Health

6.1 THE PROGRAMME of family within a new programme outline. It groups health reflects the priorities iden­ them according to (a) strengthening of the tified by countries in this field, family health component of health care namely maternal and child health, family systems, in particular within primary health planning, nutrition, and health education. care ; (b) development of technologies and They form an integrated component of advancement of knowledge in family health; health care and are closely linked with the and (c) development of intersectoral strat­ other essential elements of primary health egies related to family health, population care. Family health care emphasizes the and development. This groupin,g has participation of families in health promo­ facilitated the integrated programming of tion and deals with the needs that cannot be complementary activities at global and met by organized health services alone. regional levels, both within the family It reinforces self-care by the family ; and health programme itself and in conjunction it involves both traditional and community with other WHO programmes, and has workers such as traditional birth attend­ allowed more coordinated and effective ants, schoolteachers and women's groups. technical cooperation with countries. While its aim is to promote the health of 6.3 Integrated family health care is the family as a whole, it gives special receiving more emphasis in most coun­ attention to the health needs of women tries, both developing and developed, for and the promotion of the healthy physical reasons of efficiency and because it cor­ ily self-reliance in promotive and preventive responds to people's preference. During work related to pregnancy and childbirth, 1978-1979 WHO worked with UNFPA and the promotion of the healthy physical and UNICEF in providing support to an and psychosocial development of children increasing number of national family health and adolescents. This broader perspective programmes-the number rose from 50 has become the forefront of current think­ in 1978 to 75 by the end of 1979 (see ing in health, and is seen in the recom­ paragraph 6.16 below). mendations of the International Conference on Primary Health Care and the Declara­ 6.4 Technical cooperation with these tion of Alma-Ata. countries was backed up by the develop­ ment of improved methods of management, 6.2 During the biennium, a medium­ training, education and technical inter­ term programme in family health was ventions, focused on the peripheral levels. developed, which consolidated activities Related health services research included

59 THE WORK OF WHO, 1978---1979 the beginning of work on the development support of breastfeeding ; the promotion of new family health indicators, better and support of appropriate weaning prac­ adapted to the management and evaluation tices ; the strengthening of education, functions of primary health care. The training and information ; the health and emphasis is on information that can be social status of women ; and the appro­ used by the family itself, by primary health priate marketing of infant-formulas and care workers, and by other development weaning foods. It recommended that there workers at local levels. should be no sales promotion, including promotional advertising to the public of 6. 5 The integration of the components products for use as breastmilk substitutes of family health and intersectoral ap­ or bottle-fed supplements and of feeding proaches is further exemplified by the bottles ; and asked WHO and UNICEF to activities related to infant and young child work out an international code for market­ feeding. A WHO/UNICEF meeting on ing infant formulas and other products that subject (Geneva, October 1979) 1 used as breastmilk substitutes. called for urgent action to promote the health and nutrition of infants and young 6. 7 Developments in technology are children and took a clear stand by stating described below under maternal and child that: health, nutrition, and the Special Pro­ Breastfeeding is . . . the natural and gramme of Research, Development and ideal way of feeding the infant and a Research Training in Human Reproduction. unique biological and emotional basis The latter is the research arm of the pro­ for child development. This, together gramme insofar as family planning, in­ with its other important effects, on the cluding fertility, is concerned. It develops prevention of infections, on the health technology for family planning and infer­ and well-being of the mother, on child tility care that is safe, effective, low-cost, spacing, on family health, on family and and simple enough to be provided within national economies, and on food pro­ the framework of primary health care; duction, makes it a key aspect of self­ it assists Member States in carrying out reliance, primary health care and current their own research programmes or in development approaches. It is therefore adapting technological advances made a responsibility of society to promote elsewhere. breastfeeding and to protect pregnant 6.8 During the biennium intersectoral and lactating mothers from any influence strategies were promoted in relation to that could disrupt it. health and population issues, food and 6.6 The meeting was a milestone event nutrition policies, legislation affecting the in that it brought together more than I 5o family, and other social support systems representatives of governments, inter­ affecting family health. WHO took part governmental and nongovernmental organ­ in numerous UNFPA missions to assess izations, individual scientists, and repre­ the needs of countries in population­ sentatives of the infant-food industry, all related fields in relation to overall socio­ as equal participants. It made numerous economic plans. practical recommendations, reached by 6.9 The status of women as related to consensus, on the encouragement and family health-and its relationship to health and socioeconomic development in general t World Health Organization. joint WHOjUNICEF meeting on infant and young child feeding. Geneva, 1979. -was reviewed. The complex changes

6o FAMILY HEALTH in the economic and social position of ation, the International Union of Health women were reviewed, in particular the Education, and the International Union of compatibility of women's roles in repro­ Nutritional Sciences ; and also with the duction, economic production and social Swedish Agency for Research and Cooper­ development, and the implications of those ation with Developing Countries. roles both for women's own health and for that of the family as a whole. Tra­ Maternal and child health ditional practices affecting the health of 6. I 3 In I 979, the International Year of women in the Eastern Mediterranean the Child, a comprehensive report on Region were examined with a view to maternal and child health was presented encouraging the beneficial practices and to the Thirty-second World Health As­ discouraging the harmful.1 sembly, outlining the health status of 6.Io Activities were initiated in I979 mothers and children throughout the on the role of the family in assuring its world, trends in the development of own health care, and on other develop­ relevant services (in particular within the ments in family health care, in the context context of primary health care), advances of changing family structures in many parts in technology, examples of action that of the world. In the South-East Asia could be taken by countries, and sugges­ Region a workshop discussed the implica­ tions as to the type of activity that would tions of family health care for the health strengthen technical cooperation. systems of the Region. In Europe, a 6. I4 The subsequent Health Assembly comprehensive family health programme resolution (wHAp.4z) gave the Organ­ was presented to the Regional Committee ization a strong mandate for the further in I979· reorientation of its policies. It urged Member States to ensure that appropriate 6. I I The family health programme is national resources were available for ma­ closely linked with the programmes on ternal and child health work and to pro­ strengthening of health services, health mote direct and massive action in line with statistical methodology and mental health, the concept of primary health care, calling and especially with the Expanded Pro­ on the support of individuals, families gramme on Immunization and the pro­ and communities, facilitating intersectoral grammes on control of diarrhoeal diseases collaboration, and utilizing all community and acute respiratory infections. workers, including traditional birth at­ 6. I z In the field of family health WHO tendants. This implied a radical change continued to work with other organiza­ in the way most of maternal and child tions of the United Nations system, and health care was organized, since tradi­ collaboration with nongovernmental organ­ tionally services have been geared to izations was intensified. Joint activities curative and rehabilitation care, with lim­ were carried out with the International ited coverage. Children's Centre, the International Feder­ 6.I 5 WHO has therefore carried out ation of Gynecology and Obstetrics, the health services research on maternal and International Paediatric Association, the child health care according to the level of International Planned Parenthood Feder- risk. The "risk approach" is a managerial tool for determining the content of ma­ 1 World Health Organization. Traditional practices ternal and child health care and family affecting the health of women and children. Alexandria, 1979 (WHO/EMRO Technical Publication No. 2). planning, and the relevant strategies, by THE WORK OF WHO, 1978-1979

means of an equitable and flexible allo­ Perinatal mortality cation of resources in accordance with the 6. I 7 Perinatal deaths account for the needs and life style of the local community. largest proportion of the persistent and Methods of implementing this concept tragically high rate of infant mortality. were tested in a few countries, and the They are closely linked with the poor results were published in 1978.! During health and nutritional status of the mother the biennium the approach was utilized and with the complications of pregnancy in Burma, Cuba, Czechoslovakia, India, and childbirth, in particular those due to Malaysia, Norway, Thailand, and Turkey; unregulated fertility. They are also as­ preliminary results indicate that it is sociated with low birth weight, which is feasible on a large scale. In the South­ both an indicator of the health of the mother East Asia Region, an analysis of require­ ments for operational research in this before and during pregnancy and a means area was undertaken. of predicting the immediate health of the child and its development in the long term. 6.16 The main focus of WHO's pro­ During the biennium, WHO started a gramme is at country level in support of study of low birth weight in different parts national maternal and child health/family of the ,world, with a view to ascertaining planning programmes, and 75% of its the most important local factors, testing resources are spent at this level. The specific preventive measures, and empha­ national programmes supported by WHO sizing the role of the community. Work (UNFPA-funded) in 1979 are listed in was carried out, initially in the Latin Table 6.1. American countries through the P AHO Table 6.1 Maternal and child health/family planning Latin American Center for Perinatology country programmes, 1979 2 and Human Development, to develop appropriate technology for perinatal care African Region Botswana, Burundi, Central African Republic, at home and at the village level. Congo,* Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar,* Mali, Mauritius, Mozambique,* Niger, Nigeria. Rwanda,• Senegal,* Sierra Leone, Swaziland, Togo, Zambia Disorders of pregnanry Region of the Americas Antigua, Belize, Bolivia, Caribbean Islands, Cayman, 6.18 Among the most important causes Chile, Colombia, Cuba, Dominican Republic, Ecuador, Haiti, Honduras, Jamaica, Mexico, of maternal mortality and morbidity are Panama, Peru, St Kitts, St Lucia, St Vincent, Trinidad and Tobago, Uruguay the hypertensive disorders of pregnancy. South-East ~sia Region A study was begun on the prevalence of Bangladesh, Bhutan,* Indonesia, Mongolia, Nepal, Sri Lanka, Thailand these disorders, and simple tools for their European Region surveillance, reporting, control and treat­ Algeria, Bulgaria, Malta, Morocco, Portugal, Turkey Eastern Mediterranean Region ment within the framework of primary Afghanistan, Democratic Yemen, Iran, Jordan, health care are being developed, concur­ Pakistan, Somalia, Sudan, Syrian Arab Republic, Yemen rently with suitable training material. Western Pacific Region Cook Islands, Fiji, Kiribati (formerly Gilbert Islands), Malaysia, New Hebrides, Papua New Guinea, Breastfeeding 8 Philippines, Samoa, Solomon Islands, Tonga, Tuvalu, Viet Nam 6.19 Breastfeeding-a key practice for • Project request submitted but not yet approved as at end of 1979. the health of the child-is declining owing to certain social and economic factors in 'World Health Organization. Risk approach for maternal and child health care. Geneva, 1978 (WHO modern society and positive action 1s Offset Publication No. 39). 2 Funded by UNFPA. 3 See also paragraphs ,6.5 and 6.6 above.

6z FAMILY HEALTH required to reverse the trend. A collabor­ psychosocial development of children and ative study was undertaken by WHO in adolescents, carried out jointly by WHO order to obtain a reliable picture of current and the USSR Institute of Paediatrics. practices in infant feeding, in particular The report gives data on development in breastfeeding. The study, funded by the first years of life. UNFPA and SIDA, was designed in two phases. In the first, information was Health of adolescents obtained from approximately 23 ooo 6.23 During I978-I979 a collaborative mother-and-child pairs in at least three research programme on the reproductive groups-rural, urban poor, and urban health of adolescents was started with a economically advantaged in nine countries. view to strengthening national research 6.20 The second phase, initiated during and training capabilities 1n this field ; the biennium, is an investigation of the important new information on the physio­ volume and composition of breastmilk. logical and psychological aspects of matura­ The results of the first phase showed that, tion in girls and boys is being collected and contrary to what had hitherto been alleged, analysed. To complement this research a the decline in breastfeeding is greatest study on the health services and health among the urban poor in developing educational aspects was completed in countries, i.e., the population at highest I 5 countries (I979), the data from which risk ; that health services were deficient confirmed that most countries neglect both in encouraging and in facilitating the special needs-especially the psycho­ breastfeeding; and that breastfeeding is social needs-of adolescents. compatible with the working and living 6.24 In the European Region, the patterns of modern society if suitable growing problem of teenage pregnancies support is provided. It confirmed the was one of the topics discussed at a regional positive correlation between breastfeeding conference on the child and adolescent in and a delayed return of menstruation, a society (Athens, September I978-see also point of importance for fertility regula­ Chapter I 5, paragraph I 5-1 I 3). The Re­ tion ; and it led the way to health educa­ gional Office for the Western Pacific con­ tional and promotional activities at regional vened a meeting on the reproductive health and national level. of adolescents (Sarawak, I979)·

Gr01vth and development Fami!J planning 6.2 I Following a series of field tests, 6.25 The provision of effective and the Organization in I978 published a acceptable family planning care within the growth chart for maternal and child health general health care system is now a priority care,! as a tool for monitoring the infant's in most areas and WHO, both at regional development that can be used both by and country level, emphasized training and the family (the mother) and by the primary health services research in family planning health worker. as part of maternal and child health care. (Details of the research carried out on 6.22 A preliminary report was com­ family planning under the Special Pro­ pleted on the study on the physical and gramme of Research, Development and Research Training in Human Reproduction, 'World Health Organization.. A growth chart for international use in maternal and child health care. Guide­ are given under that heading below). lines for primary health care personnel. Geneva, 1978. Guidelines for health workers were pre- THE WORK OF WHO, 1978--1979 pared on abortion care, female sterilization, organization of day care for young children. intrauterine devices, injectable contracep­ The International Year of the Child pro­ tives, and oral contraceptives as they affect vided an opportunity for emphasizing the health services. maternal and child health as a fundamental element of primary health care and socio­ 6.2.6 In the South-East Asia Region a economic development, and for stressing consultation on requirements for research the need for concerted effort on the part in the family planning aspects of family of national groups and intergovernmental health programmes (New Delhi, March and nongovernmental organizations to 1979) made recommendations on the tech­ promote a long-term investment in child­ nological, psychosocial, and health services hood by all development sectors. WHO's aspects of such research. regional offices cooperated with Member States in setting up multidisciplinary and Training intersectoral national commissions to plan 6.2.7 The UNICEF/WHO Joint Com­ such action, both immediate and long-term. mittee on Health Policy (January 1979) reviewed the programme of support for International Year of the Child the training in maternal and child health/ 6.2.9 The International Year of the family planning (within primary health Child also provided an opportunity for care) of health and other workers in socio­ raising awareness and stimulating long­ economic development. It outlined a new lasting action to benefit children. Various approach-intended to promote national conferences and workshops were held, self-reliance-based on the use of health bringing together thousands of profes­ teams, extensive field training, and curricula sionals, in a variety of disciplines, from that take into account the priorities of the both developing and developed countries. community and indeed are built up from As part of a symposium on the Child in task analyses made at local level. The the World of Tomorrow (Athens, June institutional support is geared to integrated 1978), WHO and UNICEF sponsored a health services research, development and workshop on innovative approaches to the training, and to exchange between institu­ basic needs of young children in develop­ tions in developing countries. This ap­ ing countries. A workshop was organized proach was adopted in the new family jointly by WHO and the International planning training programme in China, Federation of Gynecology and Obstetrics which receives WHO and UNFPA sup­ (Tokyo, October 1979) on innovative port ; it is also reflected in the national approaches to maternal and neonatal care teacher-training programmes in which as part of primary health care. Special WHO is collaborating in Papua New efforts were made to urge professionals to Guinea, Sudan, Turkey, and the United take the lead in their own countries to Republic of Cameroon, and in which ensure that maternal and child health had teachers are trained at community level. an appropriate place in the formulation of national strategies for attaining health for Intersectoral activities all by the year 2.ooo. 6.2.8 Intersectoral services in 1978-1979 6. 30 The Regional Committee for were mainly concerned with children, Africa commemorated the twentieth an­ adolescents, and young people; they cov­ niversary of the Declaration of the Rights ered school health programmes and the of the Child by a special exhibition at its FAMILY HEALTH

1979 session. The Regional Committee with a number of countries and by par­ for Europe discussed a medium-term pro­ ticipating in the work of the ACC Sub­ gramme for maternal and child health committee on Nutrition and its Advisory in 1979. Child health was the theme of Group. the Technical Discussions at the Regional Committee for the Eastern Mediterranean 6.34 Attention during the biennium in 1978, at which time the Committee focused on the promotion of breastfeeding urged governments to increase their efforts, and adequate weaning practices. The most fix targets for the next ten years, determine notable development in the nutrition pro­ their strategies, and allocate the resources gramme was the formulation of an action­ to attain those targets. oriented research, development and train­ ing programme, which was approved by 6.p The theme for World Health Day the Thirty-first World Health Assembly in 1979 was : "A healthy child, a sure and by the global Advisory Committee future." A kit of relevant material was on Medical Research. Its object is to sent to all countries ; the March 1979 issue translate into operational activities the of World Health was devoted to child latest knowledge on how to improve health ; and a special publication was nutritional status through action at com­ sponsored by WH0.1 munity level ; emphasis is on meeting the nutrition needs of young children, includ­ ing infants during the weaning period, by Nutrition foods that are both acceptable and locally 6. 32 Malnutrition especially as it affects available. The planning of the programme young children is one of the most serious involved meetings of nutritionists, health and widespread problems in the world administrators and social scientists from today. Combined with infectious disease countries in different regions, and sub­ and unregulated fertility, it causes the death committees on nutrition were set up by of millions, and retards the growth and the global and regional advisory com­ development of an even greater number. mittees on medical research. Specific pro­ Contrary to earlier and more optimistic jects were started in the African and expectations, the problem is increasing. South-East Asia Regions. The elimination of malnutrition, although 6. 3 5 Feasibility trials on the integration not solely a public health problem, is of nutrition and nutrition-related activities fundamental for the attainment of an into primary health care were held in India, acceptable level of health. An adequate Sudan, Somalia, Thailand, and the United supply of food and a proper standard of Republic of Tanzania. Home-made wean­ nutrition are essential to primary health ing foods were tested in India and Sudan. care.

6. 3 3 The basic importance of suitable Interaction of malnutrition and disease food and nutrition policies for socio­ 6.36 In view of the interaction of economic development is increasingly rec­ malnutrition and diarrhoeal diseases, joint ognized, and WHO assisted in formulating activities were carried out by the two such policies by its technical cooperation programmes, in particular the formulation of guidelines for child care in the light of 1 Faulkner, F., ed. Prevention in childhood of health problem; in adult lift. Geneva, World Health Organ­ this interaction. The state of knowledge ization (in press). on the interaction of malnutrition and the THE WORK OF WHO, 1978-1979 host response to pathogens was reviewed WHO works closely with F AO in this and areas for research identified. regard.

Training Specific nutritional problems 6. 37 The legacy of "vertical" or iso­ 6.40 To bridge existing gaps in know­ lated nutrition programmes within the ledge of human energy and protein require­ health services remains an obstacle. More­ ments, a collaborative research project over health workers at all levels, but continued in several institutions in Central particularly the community level, are in­ America and South-East Asia. A manual on the management and treatment of adequately trained in nutrition. During severe protein-energy malnutrition was the biennium therefore WHO emphasized training, including curricula based on the prepared in 1979, guidelines being given for circumstances where resources are actual tasks the trainee would be called limited, e.g., health care in rural areas. upon to carry out at peripheral level. A model for training community health 6.41 The control of specific nutritional workers was developed in collaboration deficiencies-nutritional blindness resulting with national institutions and was tested from vitamin A deficiency, endemic goitre at courses in which nearly Ioo people and cretinism caused by iodine deficiency, from some 40 countries participated and nutritional anaemia due to iron and (Hyderabad, India, 1978; Ibadan, Nigeria, folic acid deficiency-continued to receive 1979 ; and Zinder, Niger, 1979). attention.

Nutritional surveillance 6.42 WHO worked with the Inter­ national Vitamin A Consultative Group in 6. 3 8 Information on the nutritional recommending a schedule for the treat­ status of the population, in particular data ment of xerophthalmia and the intra­ on those at high risk, has been given high muscular administration of vitamin A priority by countries in recent years. preparations. The Group also reviewed Various methodological and operational reports on prevention programmes in problems were studied in collaboration Bangladesh, Brazil, Central America, Haiti, with institutions in Colombia, Guatemala, India, Indonesia, Iran, the Philippines, Israel, Italy, and Sri Lanka. Guidelines Sri Lanka, and Thailand, and noted the for the use of anthropometric data of progress made in the fortification of foods children and a set of international reference to prevent vitamin A deficiency. A task data on weight and height were prepared. force on the control of vitamin A defi­ ciency and xerophthalmia (Manila, No­ 6.39 Some progress was made in estab­ vember 1979) made important recom­ lishing nutritional surveillance systems for mendations for a programme of research use in planning or for early warning. and action. A working group on nutritional surveil­ lance was established by the ACC Sub­ 6.43 Research on methods of prevent­ committee on Nutrition and met in 1979. ing nutritional anaemia continued in various Information on nutritional status is in­ parts of the world. It included studies on creasingly being combined with agri­ the feasibility and efficacy of iron fortifica­ cultural, social and economic data to tion of sugar, salt and fish sauce ; and the improve overall planning and evaluation ; field testing of controlled-release iron

66 FAMILY HEALTH

preparations for oral use, to ascertain of Tanzania, and Yugoslavia-have under­ their efficacy and the absence of side taken studies in order to find the most effects. effective pattern of community participa­ tion as an element of primary health care 6.44 A comprehensive review of the in general and for solving specific health prevalence and control of endemic goitre problems in particular. Many of the was undertaken. The results 1 show clearly investigations are based on the con­ that endemic goitre is still a significant clusions of the UNICEF/WHO study on public health problem affecting large popu­ community involvement in primary health lations, and that despite the existence of care, carried out in 1976-1977· cheap and easily administered techniques there is no widespread application of 6.47 Health education in support of control measures. national family health programmes was an important part of WHO's work at regional 6.45 A joint FAO/WHO consultation and national level during the biennium, on carbohydrates in human nutrition, with and was particularly relevant at a time special emphasis on infants and young when countries were increasingly recog­ children (Geneva, September 1979), re­ nizing the family as the basic health care viewed the influence of carbohydrates on unit and childhood as the crucial period the development of caries, diabetes, and in which health behaviour is inculcated. hypertension and discussed the processing In the Region of the Americas, particularly of starch, the significance of indigestible in the Caribbean area, programmes in carbohydrates, and intolerance to lactose. family life education were promoted; in several of the islands these were combined with youth and school programmes. In Health education the South-East Asia Region a survey was 6.46 People's own responsibility for made in nine countries as a basis for the attainment of health can be assumed collaboration with governments and with only when individuals or families are UNESCO in revising the health component educated, motivated, and psychologically of curricula in primary and secondary committed to making a reasoned choice schools. from among the alternatives for health 6.48 In the context of health education action and really participating in such as part of socioeconomic development, action. However, health education must a workshop-one of a series organized be based not only on personal motivation with F AO, ILO, UNESCO, and the but also, and more importantly, on cultural International Planned Parenthood Feder­ patterns and social systems. There can ation-brought together a number of thus be no a priori stereotype for health community workers in health, agriculture education work. This is especially true and education, and representatives of of community participation, which is a national family planning associations, to key to primary health care and the pro­ discuss education and communication for motion of which forms a major part of family well-being through integrated rural health education. A number of coun­ development (Ouagadougou, 1978). tries-Sri Lanka, Sudan, United Republic 6.49 In view of the need for social, 1 De Maeyer, E.M. et al. The control of endemic goitre. anthropological and behavioural parameters Geneva, World Health Organization, 1979. on which to base health education, WHO THE WORK OF WHO, 1978--1979 organized a task force on research in health 6. 53 The opportunities that are offered education for family health (Geneva, Oc­ for health education when people are tober 1978), which made a number of using health facilities were emphasized. recommendations for strengthening this Health education for patients in hospitals type of research. New emphasis was was especially strengthened in Bangladesh, placed on the role of the individual and Mongolia, and Sri Lanka. the family in self-care and health promotion, as well as on the importance of community­ 6.54 Various forms of communication organized networks for health action. with the public were explored. In the African Region, a meeting discussed the 6.50 In providing training in health utilization of communication sciences for education for both health and other workers health promotion (Brazzaville, 1979), and in socioeconomic development, WHO an inventory was made of regional health worked with many countries: Benin, Fed­ education material and of institutes pro­ eral Republic of Germany, Gabon, India, ducing such material. In the Western Indonesia, Malaysia, Nigeria, Papua New Pacific Region the training of personnel Guinea, Thailand, Turkey, the United in audiovisual technology-including the Kingdom, and Yemen. Assistance was designing, pretesting, and production of given inter alia in producing guidelines on audiovisual aids and their use through health education for primary health workers. both modern and folk media-was con­ 6.51 There are a number of problem tinued. areas in health education, e.g., where it relates to family planning, infant feeding, 6. 55 At policy level regional panels of childhood diseases, and tobacco smoking. experts were organized and in two regions The health education manual for workers -Africa and the Eastern Mediterranean­ in expanded programmes of immunization meetings of members of those panels have was revised and was adapted at local level already been held. in several countries. In the European Region a survey on tobacco smoking 6.56 In 1979 the Technical Discussions covered among other subjects the health at the twenty-ninth session of the Regional education measures taken in the countries Committee for Africa had as their theme : surveyed. "Community health information and edu­ cation". In the Americas, preparations 6. 5z Health education in relation to began for the Technical Discussions at the malaria control is exemplified by the Regional Committee in 1980. The theme support given to Papua New Guinea, will be : "Community health education­ where community involvement was en­ Evaluation of present programmes, new couraged by decentralizing antimalaria approaches and strategies." operations to the level of the village council, which then selected the local spraymen. In Kiribati 1 health education Special Programme of Research, Devel­ was carried out in conjunction with opment and Research Training in environmental sanitation programmes and Human Reproduction a series of workshops was organized to prepare health inspectors for their new 6.57 The Declaration of Alma-Ata educational role. affirmed that family planning was a basic component of primary health care. Had 1 Formerly Gilbert Islands. the conference been held ten years earlier,

68 FAMILY HEALTH it is doubtful whether such a statement the needs of developing countries.1 In 1979 would have been made, or the contro­ it was able to marshal the talents, skills versial topic of family planning even and resources of scientists from 70 coun­ mentioned. Despite the gains in accept­ tries, of which 4 5 were developing coun­ ance of family planning at governmental tries. This collaboration was highlighted and community levels, there are still many by the representative of the Executive more people demanding and in need of Board at the Thirty-second World Health such services than are actually practising Assembly (1979), who stated that: family planning. Considerable differences Over 70 countries were involved in such of opinion exist as to the reasons for this collaborative research and strengthening gap and how to bridge it. The protagonists of institutions, in which Member States, fall roughly into three camps : the "hard­ through their scientists and adminis­ ware" enthusiasts, the "software" ad­ trators, themselves planned, conducted, vocates, and those who champion a blend monitored and evaluated the research. of the two. That had led the Executive Board, at its meeting in January 1979, to describe the 6. 58 The hardware enthusiasts consider programme as a unique venture in inter­ that the answer lies in better birth control national collaboration in the health technology, i.e., a wider range of effective, field. 2 safe and acceptable contraceptives. The software advocates point out that, where 6.6o In research, the Programme is motivation is high and the service infra­ concerned with both the hardware and structure satisfactory, currently available the software of fertility regulation through methods are largely adequate. The third studies on the safety and effectiveness of group recognizes the shortcomings of both current methods of birth control ; the hardware and software, but also their development of a variety of new tech­ interdependence. They point to the niques ; the psychosocial aspects of family inadequacy of present technology, and to planning ; the delivery of family planning the small choice of methods available. care ; and the diagnosis and treatment of They stress that family planning is a rela­ infertility. In the strengthening of research tively new area of care, with strong capabilities, it collaborates with national personal and cultural connotations that authorities in building up the manpower are frequently not understood, and that and facilities that will enable developing it demands a delivery system that will countries to plan and to carry out research, reach large portions of the population adapt technology, and contribute fully to and is suited to local circumstances. the advancement and application of science. All three viewpoints are represented among This mix of activities in the Programme the Member States of WHO. was endorsed by the Health Assembly in 1978 (resolution WHA31.37), with the Objectives of the Programme proviso that health services research should be intensified. 6.59 The WHO Special Programme of 1 A fuller description of the programme can be Research, Development and Research found in Special programme of research, development and Training in Human Reproduction addresses research training in human reproduction, Seventh annual itself to research on fertility regulation, report, 1978; and Eighth annual report, 1979· 2 Thirty-second World Health Assembly: Summary and to the strengthening of capabilities for records of committees (WHO document WHAp/1979/ such research, in both cases directed to REC/3), p. 74• THE WORK OF WHO, 1978-1979

Resources for research from developing countries. It endorsed the continuation and expansion of the different 6.61 Research in human reproduction approaches adopted. suffers from an acute shortage of manpower and of facilities, particularly in developing 6.64 Research training grants. To date, countries, in many of which there is still over 3 5o research training grants and not a single scientist in the field of human grants to enable scientists to visit other reproduction. Few have research groups institutions have been awarded, represent­ of the size that can provide the "clinical ing an investment of over US$ 4 million. mass" needed to generate ideas and translate To assess the impact of this training, them into research that is both original questionnaires were sent to all scientists and relevant to local conditions. who had completed their training by September 197S. Replies were received 6.62 The variety of approaches used from So% of those holding research in the Programme to strengthen research training grants and 90% of those receiving and development capabilities in developing grants to visit other institutions. More countries is shown in Table 6.2. than 90% of the first group considered that the training had met their needs in Table 6.2 Institution-strengthening activities terms of content, length of training, and facilities at the training institution (only Research manpower - Research training and grants to visiting scientists one trainee complained that the training - Research training courses he had been given was too sophisticated - Involvement of scientists in planning, coordination and evaluation of research to be of general use to him afterwards) ; - Financial support for salaries of investigators and other personnel 93% answered that they had been able, - Consultant services, including WHO staff on return to their home institution, to - Workshops, conferences and symposia apply what they had learnt; and over Research facilities So% were still engaged in research on - Provision of equipment, supplies and spare parts for: epidemiological research human reproduction/fertility regulation at clinical research laboratory research the time of the survey. Moreover 7 r % health service research computing and data analysis of the respondents were currently training - Maintenance of equipment other research workers, so that the hoped­ - Schemes for quality control and standardization of methods and reagents for multiplier effect was being attained. - Provision of books, journals, and devices for information retrieval 6.65 Questionnaires were also sent to Other activities - Establishing guidelines for scientific and ethical review the home institutions of trainees, which of research reported that 14% of the trainees had not - Transfer of technology for use in manufacture - Assistance in obtaining patents returned. However, this is not a measure of brain drain, since So% of those who did not return to their home institution Research training took up work in another institution in their home country. 6.6; In 1979 the Advisory Group to the Programme made an in-depth assess­ 6.66 Ninety-five per cent of recipients of ment of the research training component grants to visit other institutions considered from its beginning. It emphasized that that the grant had met their needs. the Programme was practically alone in providing opportunities for research train­ 6.67 Of the I 2S grants of both types ing in human reproduction to scientists awarded between October 1977 and Oc- FAMILY HEALTH tober 1979, all but four went to scientists 6.70 Five collaborating centres for clini­ from developing countries. cal research in human reproduction in developing countries-in Bangkok, Bom­ 6.68 Research training co11rses and ll'ork­ bay, Chandigarh (India), Mexico City, shops. The courses organized by the Pro­ and Singapore-are strengthening the re­ gramme in 1978 and 1979 are shown in sources of other institutions in their own Table 6+ country or region. For instance, the centre in Mexico City provides a two-year training Table 6.3 Research training courses, 1978-1979 course in human reproductive biology, and assists trainees in setting up research nuclei in provincial universities. The Title of course and country or area Duration from which trainees came centre in Bangkok has organized a number of short courses, for scientists in the capital Application of epidemiology to research in fertility regulation and from provincial universities, on such China, Egypt, Thailand, Turkey 6 months subjects as maintenance of research equip­ Clinical pharmacology of fertility control ment, instrumentation for research in drugs Brazil, China, Egypt, Mexico, Philip­ reproductive biology, and analytical and pines, Singapore, Thailand 1 to 2 years quality control methods in clinical Recent advances in human reproduction Brazil, Chile, Cuba, Egypt, Kenya, chemistry. Mexico, Pakistan, Philippines, Singapore, Thailand 2 weeks Theory and practice of radioimmuno­ Collaborating centres assay (three courses) Argentina, Brazil, Chile, Cuba, Egypt, Kenya, Mexico, Singapore, 6. 71 The 40 collaborating centres are Tunisia, USSR 1 month each major resources for research, and those in Botanical methods in research on plants for fertility regulation developing countries are the main focus of Bangladesh, Brazil, Hong Kong, lnoia, Kenya, New Caledonia, the Programme's institution-strengthening Paraguay, Republic of Korea, act1v1t1es. Twenty-seven of them are Sri Lanka, United States of Amer­ ica 1 week located in developing countries. The Health services research in family network of centres for clinical research, planning Turkey 2 months and the clinical departments of the re­ search and training centres (see following paragraph) conduct most of the clinical 6.69 Training l?J collaborating centres. The research described below. In 1979 about four WHO collaborating centres for re­ 50 ooo subjects were involved in WHO search and training in human reproduction multicentre clinical trials, and in other have to date, using WHO funds, trained studies at the community level. Several nearly 500 scientists by means of short of the collaborating centres in clinical courses on specific topics and by involving research in developing countries have them in research projects. In addition become important national research re­ these centres, and several of the collabor­ sources. In many cases their directors are ating centres for clinical research in human members of advisory committees of the reproduction referred to below, run courses ministry of health, national family planning -for teachers in medical and nursing bodies, drug regulatory authorities, or schools, clinicians and public health work­ medical research councils. ers-on the implications for clinical prac­ tice and community health of recent 6.72 The four research and training research findings. centres are located in Delhi, Moscow, THE WORK OF WHO, 197S-1979

Stockholm, and Buenos Aires/Santiago, in Research on current methods of fertility regu- institutions that have the broad research lation basis, the facilities and the necessary 6.76 The questions of safety and efficacy number of scientists to allow multi­ most frequently raised in the past two disciplinary research and research training. years relate to the drugs or devices to be Two additional centres, in Nairobi and in chosen for national family planning pro­ Shanghai (China), are being strengthened as grammes ; the medical reasons for the potential research and training centres. disturbingly high discontinuation rates with practically all methods ; the safety 6.73 Several collaborating centres pro­ vide resources for the Programme's re­ of injectable contraceptives ; and the long­ term effects of birth control methods, e.g., search in specialized areas, e.g., health the risk of cancer, subsequent infertility, services research, infertility, epidemiolo­ or congenital anomalies. gical methods, and immunoassay of repro­ ductive hormones. Over the past two 6.77 The Programme's research on the years, a major effort has gone into building safety and efficacy of current methods of up institutions in Brazil, Hong Kong, the fertility regulation relates to oral contra­ Republic of Korea, and Sri Lanka, and ceptives, intrauterine devices, injectable these centres, together with two others, contraceptives, natural family planning in the United Kingdom and the United methods, female sterilization, and tech­ States of America, will constitute a net­ niques for termination of pregnancy. work for research on plants that can be Selected studies completed in 1978-1979 used for fertility regulation. are described below. 6.74 To ensure comparability of results 6.78 Oral contraceptives. In a study in in the multicentre trials and other collabor­ India and Thailand on the use of oral ative studies, the programme of standard­ contraceptives by inadequately nourished ization and quality control of laboratory women, after one year of use no differences procedures has been extended from radio­ were noted in continuation rates, clinical immunoassay of reproductive hormones signs, complaints, or changes in metabolic and clinical chemistry to various other indices that could be attributed to nutri­ laboratory procedures. A total of 172 tional status or to differences in the oestro­ laboratories in 52 countries are now gen content of the two preparations included in this programme. studied, the amount of progestogen being the same ; the changes in metabolic indices 6.75 In addition to equipment and were essentially the same as those observed supplies for projects and collaborating in developed countries. Most of the centres, journal subscriptions, small quanti­ subjects showed clinical or laboratory ties of general laboratory supplies, minor evidence of vitamin deficiency, but the equipment, chemicals, reagents, labelled use of the oral contraceptive did not cause compounds and spare parts are provided further deterioration. by the Programme to scientists in develop­ ing countries or in those developed coun­ 6.79 Following the recommendations tries where currency restrictions limit of a scientific group, 1 eight institutions in purchases from abroad. In 1979, 78 1 WHO Technical Report Series, No. 619, 1978 departments or institutions in 30 countries (Steroid contraception and the risk of neoplasia. Report of received journals and supplies. a WHO scientific group). FAMILY HEALTH six developing countries took part in a beagle was an inappropriate animal model ; pilot case-control study 'on the possible and that the data from monkeys resulted assoc1at1on between hormonal contra­ from gross overdosage. Thus there was no ceptives and neoplastic disease, which toxicological reason for discontinuing the has now been expanded into a full-scale use of DMPA in family planning pro­ study. grammes. For NET-OEN the conclusion was that no modification was required to 6.8o Intrauterine devices (IUDs). To the extensive WHO studies. assist national family planning programmes in choosing between the plastic-only intra­ 6.83 Natural fami!J planning methods. uterine device and the newer copper­ Two main studies on the effectiveness of releasing devices, clinical trials have been the two natural family planning methods, carried out since 197 5 in Cuba, Egypt, the ovulation method and the sympto­ Hungary, India, the Philippines, the Re­ thermal method, were completed in 1979 public of Korea, Singapore, Thailand, in centres in Colombia, El Salvador, the Union of Soviet Socialist Republics, India, Ireland, New Zealand, and the the United Kingdom, the United States Philippines. The Advisory Group to the of America, Yugoslavia, Zambia, and Programme, at its September 1979 meeting, Berlin (West). Data on a total of 55 3 57 recognized that these two studies had woman-months of experience had been fulfilled a useful function in providing a analysed by March 1979, and a statement scientific assessment of the two methods ; was widely distributed to ministries of this enabled it to conclude that the methods health, national family planning programme had very limited application, particularly administrators, and other agencies con­ in developing countries. cerned with family planning ; its con­ clusion was that the Copper T zzoC device 6.84 Termination of pregnancy. The tech­ was more effective and was associated with nique for the early (fifth to sixth) week a smaller increase in menstrual blood loss abortion known as "menstrual regulation" than the Lippes Loop D. The Copper has been promoted by various agencies T zzoC was therefore recommended as a and individuals on the basis of its sim­ suitable alternative for national family plicity, low cost and supposed minimal planning programmes. complications. A WHO trial comparing 6.81 lrijectable contraceptives. Only two different types of equipment and different long-acting injectable contraceptives are times of termination of pregnancy was available for widespread use : depot­ completed in 1979; it covered 3137 women medroxyprogesterone acetate (DMPA), recruited in centres in India, the Republic which has been in use for a number of of Korea, Singapore, the United States of years, and the more recently marketed America, and Yugoslavia. When abortion norethisterone oenanthate (NET-OEN). performed during the fifth or sixth week of pregnancy was compared with that at 6.82 Three statements were issued by the seventh or eighth week, it clearly WHO in 1978 and 1979, based on careful emerged that safety and effectiveness were review by the Programme's Toxicology far greater at seven or eight weeks. Panel of animal data provided by industry and by WHO clinical studies. They con­ 6.85 Extensive studies on the short­ cluded that the disquieting data on DMPA term complications of induced abortion, in beagles was not relevant, since the conducted by an Indian task force collab-

73 THE WORK OF WHO, 1978-1979

orating with the Programme, were com­ methods which would considerably extend pleted in 1979. The complication rates of acceptance and 'use, e.g., postcoital pre­ first-trimester vacuum aspiration in the parations, once-a-month pills, drugs for Indian setting were similar to those found men, kits to predict the fertile period, in other countries. The data from this vaccines, and preparations from indigenous study support the conclusion from other plants. WHO studies that the seventh to eighth week of gestation is the optimal time for 6.88 Two approaches that were shown termination of pregnancy. Second-tri­ during 1979 to be less promising-intra­ mester abortions showed mortality rates cervical devices and the intranasal adminis­ equivalent to or higher than maternal tration of contraceptive steroids-are being mortality rates in the same settings in discontinued. To concentrate manpower India, thus emphasizing the need to reduce and financial resources on a smaller number the incidence of second-trimester abortion of products, the Advisory Group, at its and develop better techniques for it when September 1979 meeting, also recom­ it is unavoidable. mended discontinuation of a number of other lines of research. Research and development of ne1v methods of 6.89 WHO studies have documented fertility regulation the increase in menstrual bleeding after 6.86 Public health authorities, clini­ the insertion of a traditional plastic-only cians and the public continue to point to IUD, or a copper-releasing IUD, and the the dangers and the crudeness of available detrimental effect of this bleeding in birth control technology, and to its failure women from developing countries where to meet the wide range of individual needs, malnutrition is common. They have also cultural requirements, and health service shown that with new hormone-releasing constraints. In developing countries, only IUDs bleeding is reduced to below pre­ about 1 5 % of women of reproductive age, insertion level with no loss in efficacy. and a much smaller percentage of men, A progesterone-releasing device developed practise family planning; and the discon­ by industry, with a maximum life-span tinuation rates for both oral contraceptives of 5 years, is being assessed in the collab­ and intrauterine devices are very high. orating centres for clinical research. To A new and improved technology would extend the life-span of the device to the undoubtedly have great impact. Industry more useful duration of 10 or more years, on the whole is not interested in producing the Programme is developing a levonor­ new contraceptives for developing coun­ gestrel-releasing device the clinical testing tries, and the developing countries alone of which is well advanced. cannot set up the research required. 6.90 To meet the demand for better 6.87 The Programme follows two main long-acting injectable contraceptives, a lines. One seeks to make present tech­ programme was started in 1976 to syn­ niques-injectable contraceptives, intra­ thesize and screen new compounds. By uterine devices, methods based on periodic the end of 1979, about 175 new compounds abstinence, barrier methods (vaginal rings), had been prepared in university labora­ and sterilization techniques-safer, more tories in Australia, Brazil, Bulgaria, Iran, effective, more acceptable, and simpler to Israel, Mexico, Nigeria, Poland, Singapore, use and to provide. The other aims at Spain, and Sri Lanka. Seven of them developing entirely new birth control show promise. This is more than a scien-

74 FAMILY HEALTH

tific breakthrough : for the first time, the programmes, decision-makers are asking Programme has shown that a multinational for more information on the psychosocial cooperative project in drug chemical syn­ background. For example, what are thesis can be established outside the people's perceptions of current family traditional channels of the drug industry. planning programmes and providers ? What is the optimal mix of contraceptive 6.9 r One aim of the Programme is to methods for a particular population ? develop inexpensive technology, primarily What characteristics do new fertility regu­ for use in developing countries, that will lating methods require if they are to be permit women to ascertain the fertile and accepted ? These and other questions infertile phases of the menstrual cycle with that point to the complex interaction greater confidence than at present. Data between cultural factors, socioeconomic were collected during 1978-1979, in dif­ development, human motivation, and fer­ ferent population groups, on variations in tility are being investigated. the excretion patterns of urinary meta­ bolites of oestrogen and progesterone that 6.95 A study in 6ooo women of pat­ could be used for monitoring ovulation ; terns of menstrual bleeding and how studies were carried out to develop non­ it is perceived was completed in 1979 isotopic assay systems for measuring these in centres in Egypt, India, Indonesia, steroid metabolites. Jamaica, Mexico, Pakistan, the Philip­ 6.92 ·For termination of pregnancy, pines, the Republic of Korea, the United the availability of a drug that could be Kingdom, and Yugoslavia. Since changes administered in the outpatient department, in menstruation are the single most com­ or even self-administered, would facilitate monly cited reason for discontinuation the provision of abortion services where of most female contraceptives, a better these are included in the family planning understanding of attitudes to and beliefs programmes of developing countries. The about menstrual bleeding has important usefulness of prostaglandins for termination implications for family planning pro­ of both first- and second-trimester preg­ grammes. Other things being equal, nancy was established in large-scale clini­ women in the cultural groups studied cal trials conducted by the Programme, tended to prefer a method that does not and the search continues for prostaglandin result in amenorrhoea ; does not reduce analogues with high efficacy but lower or increase the amount of blood loss ; rates of gastrointestinal side effects. ensures that the periods of bleeding are relatively short and occur regularly; 6.93 Basic biological and chemical re­ permits the prediction of those periods search was carried out on other much with a fair degree of accuracy ; and does needed technology, e.g., contraceptive not result in the production of blood of methods for men, postcoital drugs, and thinner consistency or a different colour vaccines. For the first two methods it from "normal" menstrual blood. included work on compounds made avail­ able by China and by the German Demo­ cratic Republic. Health services research 6.96 The scope of health services re­ Prychosocial research in fami(y planning search was increased, as shown in Table 6.4, 6.94 Both for evolving national family and a cost-analysis component has been planning policies and for improving local added to many studies. The studies are

75 THE WORK OF WHO, 1978-1979 taking place in Canada, Colombia, Egypt, research and research trammg in the India, Kenya, Malaysia, Mexico, Nigeria, services aspect of family planning was Pakistan, the Philippines, the Republic of designated at the Institute of Community Korea, the Syrian Arab Republic, Thailand, Medicine, Hacettepe University School of Turkey, the United Kingdom, and Vene­ Medicine, Ankara. In I979 the centre zuela. conducted a two-month course on health services research and family planning. Table 6.4 Health services research on family planning Infertility Need for services: 6.99 Governments are increasingly - health rationale for family planning - traditional methods of child spacing stressing the social, public health and - impact of illegal abortion on health and health semces service implications of infertility, which Use of different categories of health personnel: nurse-midwives; theatre nurses; medical students; lay is estimated to affect between 5 % and 10% workers; supervision of field personnel of couples throughout the world ; in some Integration of family planning with other health activities areas, its prevalence is alleged to be much Use of different methods of delivery for services higher. For these reasons, and because Community participation in planning of services infertility remains an aspect of health care Field testing of contraceptives new to a programme plagued by lack of standard definitions, Cost-analysis studies inadequate knowledge of the etiological factors, questionable diagnostic procedures, 6.97 Two governments requested col­ and therapeutic measures of doubtful laboration in extending to the whole of value, a task force on the diagnosis and the country the WHO studies completed treatment of infertility was established in I978, namely (I) the study in Turkey on in I978. A manual for the standardized the training and supervision of nurse­ evaluation of the infertile couple was midwives for IUD insertion and other prepared, along with standard forms, and family planning tasks; and (z) the study these were pre-tested in three developed in Thailand on female sterilization by and three developing countries. The first theatre nurses. The findings of a second phase of a prevalence study of infertility study in Thailand, on the performing of in the East Province of the United Re­ vasectomies by medical students, were public of Cameroon showed the rate of taken into account in revising the under­ primary infertility to be I I % and of graduate medical curriculum. Such re­ secondary infertility to be 3 5 %, half of search, like other studies on the use of the primary and a third of the secondary nonmedical staff, showed that with ap­ infertility being apparently attributable to propriate training such staff can perform the man. as well as, or better than, physicians. On this basis, national legislation is being Dissemination of injormatio1t changed and the reluctance of the medical establishment overcome. 6.Ioo Within the Programme, the shar­ ing of experience and information is 6.98 One of the main constraints on largely achieved through meetings of the development of health services re­ investigators and of task force steering search has been the shortage of personnel committees. In I978-I979 more than I2o with expertise in the several disciplines such meetings took place. Other mech­ required. A collaborating centre for anisms include newsletters on the pro- FAMILY HEALTH gress of specific studies, visits by staff and to the publication of the proceedings of consultants to projects, and grants for ten symposia. scientists to visit other institutions. Coordination 6.101 The wider dissemination of infor­ mation takes place mainly through publi­ 6.1oz The annual meetings of the cations, symposia, the issuing of guide­ principal agencies and medical resea~ch lines interpreting research results, and the councils conducting or directly supportmg provision of journal subscriptions. During research on the biomedical aspects of the biennium nearly 1ooo publications family planning and infertility took place resulted from research supported by the in September 1978 and 1979. The agencies Programme. Twenty-one WHO symposia reviewed their programmes, discussed co­ were organized-in Bulgaria, Cuba, Fiji, ordination and funding, and examined India, Kenya, Mexico, Nigeria, the Re­ areas where complementary action, col­ public of Korea, the United Kingdom, laboration or replication were required, the United Republic of Cameroon, the as well as areas of relative neglect. These United States of America, and at WHO meetings, which complement the frequent headquarters. Some provided scientists contacts between agencies at working level, and public health administrators with an showed that there were few areas of overview of recent advances in fertility duplication or overlap. Several agencies regulation ; others were on specific sub­ are in fact collaborating in joint projects. jects, e.g., infertility, psychosocial research, contraceptive methods for men, long­ acting contraceptive agents, oral contra­ Funding ceptives, immunological methods, and the use of nonhuman primates for research 6.103 The Programme is largely fi­ on reproduction. Guidelines on IUDs 1 nanced by voluntary contributions. For and injectable contraceptives were issued 1979, the donors were Canada, Denmark, for the use of public health administrations, Finland, India, Mexico, Norway, Sweden, manuals on IUDs were prepared for mid­ Thailand, the United Kingdom, and wives, and manuals on the analysis of UNFPA. In spite of the generous con­ semen for andrologists. Support was given tributions however, the income required to meet the US$ zz.6 million budget approved for 1979 fell short by US$ 6.1 1 Gray, R. H. Manual for the provision of intrauterine devices ( IUDs). Geneva, World Health Organization, million. A number of activities had to be 1980. discontinued or delayed.

77 Chapter 7 Mental Health

7.1 THE PERIOD 1978-1979 saw the services is not trained to deal with these implementation of the first phase matters. of the medium-term programme (3) A new approach to the psycho­ in mental health, formulated after consulta­ social aspects of health in general, tion with the Member States that had which entails not only attention to the requested the Director-General to develop psychological side effects of rapid soci?­ new activities in response to their urgent economic change but also a partnership mental health problems, and approved in between mental health workers and 1978 by the Thirty-first World Health those working in disciplines or social Assembly (resolution WHA3I.ZI). The sectors other than health, e.g., welfare, scope of the programme was considerably labour, and education. The most expanded and it now covers not_ on_ly p~e­ striking examples of this approach have vention and control of psychiatric dis­ been in the work carried out on the orders-the traditional concern of the psychological aspects of uprooti?g, the mental health professions-but also several mental health impact of apartheid, and pew areas of work, including : the consequences for health of disinte­ (I) Programmes concerned with neuro­ gration of traditional family patterns. logical and psychosomatic disorders and with alcohol and drug dependence. 7. z The extension in scope of the pro­ gramme required a strict select~on of (z) The application ·of mental health priorities. Moreover new strategi~s had knowledge in general health care. Many to be established for programme Imple­ techniques, in themselves effective, have mentation. Among them, the system of failed because insufficient attention was coordinating groups at country, regional given to the psychology both of those and local level has proved the most useful receiving and those providing health (see paragraphs 7.48 to 7·5 5 below). care ; over-reliance on technology has led to a dehumanization of medicine even where such technology is scarce ; Community health services and health and up to one-fifth of all the contacts of manpower general health care services are with people whose problems are mainly 7·3 WHO continued its work of incor­ psychological. Even so, in most coun­ porating essential elements of mental he~lth tries the staff of the general health into primary health care. Seven developmg

THE WORK OF WHO, 1978-1979 prehensive community care by effecting retarded patient and his family require changes in the structure and organization action not only by the health sector but of existing services. A study was made also by other government departments. of crisis admission units and emergency psychiatric services in Europe, their func­ tions and shortcomings being examined in Social and p!JchCJlogical dimensions of health the light of the increasing demand for 7. I I A series of activities focused on help in dealing with sudden episodes of the assessment of the social and psycho­ emotional illness and acute stress. logical dimensions of health, the measure­ 7.8 Collaboration was extended to sev­ ment of these two components in oper­ eral countries in the Eastern Mediter­ ational terms, their incorporation into ranean Region-Afghanistan, Democratic routine recording and reporting at primary Yemen, Egypt, Iraq, Kuwait, Libyan Arab health care level, and their utilization for Jamahiriya, Oman, Saudi Arabia, Sudan health service planning and evaluation. and the Syrian Arab Republic-in develop­ Seven countries-Bulgaria, Ghana, Kuwait, ing their manpower resources and restruc­ Panama, Papua New Guinea, Thailand, turing their psychiatric facilities. and the United States of America­ collaborated in a project on the monitoring of mental health needs and reported on Mental health of children the collection and utilization of data for mental health planning in their country. 7·9 Work on the mental health prob­ A manual on the mental health component lems of childhood began in I979 in of health statistics was drafted and sub­ developing countries, with a view to mitted to a group of experts for review. planning relevant and practical programmes Following a comparative review of the for the psychosocial development of chil­ statistical indicators used by countries in dren. The UNICEF Executive Board their official publications, indicators for (May I979) approved proposals for joint mental health projects were proposed and action with WHO in this field; and work were applied in selected predictions for was supported by the United States the period I98o-2ooo. An interregional National Institute of Mental Health. Pro­ workshop was organized on the classifi­ grammes for early stimulation of children cation, recording and reporting of psycho­ at risk were promoted in ten countries in logical and social health problems that can the Region of the Americas. A UNDP/ be dealt with at primary health care level. UNICEF/WHO workshop took place in the Western Pacific Region on behavioural 7.I2 In the global programme for principles in the development and manage­ health care of the elder!J, a work on ment of community health programmes, prevention of mental disorders and long­ with special reference to the needs of term hospitalization of the elderly was children and adolescents (December I979)· published.1

7.Io In the South-East Asia Region, 7. I 3 Mental health legislation is increas­ an intercountry workshop on mental retar­ ingly recognized as a key element in dation was held. Baseline data were obtained from most countries, and the recom­ 1 mendations made gave full recognition World Health Organization. Psychiatric care in the community. Copenhagen, 1979 (Public health in Europe, to the fact that the problems of the mentally No. 10).

So MENTAL HEALTH

ensuring equitable mental health care and of alcohol consumption in urban and rural preserving the rights of the mentally ill. communities ; existing resources or mea­ In the course of I978-I979 WHO published sures for dealing with them ; and ways of further material 1 relating to the interna­ improving the community response. The tional review of such legislation which it project has been in operation for three had completed in I 977. Direct technical years with the collaboration of study teams cooperation was undertaken with a number in Mexico, the United Kingdom and of countries where new legislation was Zambia, and it is now being extended to being drafted or enacted. A further review other countries. A second project, still of the more recent mental health laws at the planning stage, will monitor the began in I979· implementation of community plans and develop model guidelines for use by 7· I4 The criterion of "dangerousness" countries. in individuals has emerged as a key issue in commitment proceedings leading to 7. I 6 An international review of pre­ hospitalization and in other legal processes vention of alcohol-related problems was involving mental health expertise (parole completed for publication with the help boards, mental health reports to courts, of collaborators in more than So countries. child custody, etc.). A collaborative study It gives planners and administrators detailed on the way the concept is used and the information on preventive measures, poli­ use to which it is put was started in six cies and programmes, together with a countries (Brazil, Denmark, Egypt, Swazi­ critical appraisal of their effectiveness. land, Switzerland and Thailand). The work Country profiles on the nature and extent on mental health legislation and the of alcohol problems, current preventive assessment of "dangerousness" was sup­ policies, and future plans were prepared ported by contributions to the Voluntary in collaboration with experts in 30 coun­ Fund for Health Promotion from the tries. A meeting of experts reviewed the United States National Institute of Mental experience of individual countries and the Health. results of recent studies, and made recom­ mendations on programmes to deal with alcohol-related problems at country, re­ Alcohol-related problems gional and global level (November I979)·

7. I 5 In I 979 the Thirty-second World 7. I 7 In the Region of the Americas, Health Assembly recognized that problems the Organization collaborated with several related to alcohol, in particular to its countries in investigating alcohol-related excessive consumption, rank among the problems and planning relevant pro­ world's major public health problems grammes. (resolution WHA32.40). It stressed the urgent need to strengthen national and 7. I 8 At a conference on public health international programmes. A sound basis aspects of alcohol and drug dependence has been laid for a WHO programme by (Dubrovnik, I978),2 representatives of 26 means of two projects. One is an investi­ Member States agreed that since I 9 5o gation of the nature and extent of the there had been a startling growth-in physical, mental and social repercussions some countries over 300 %-in the con-

1 Curran, W. J. & Harding, T. W. (1978). The law 2 World Health Organization. Public health aspects and mental health: Harmonizing objectives. Inter­ of alcohol and drug dependence. Copenhagen, 1979 (EURO national Digest of Health Legislation, 1977, 28: 725-886. Reports and Studies, No. 8).

81 THE WORK OF WHO, 1978-1979

sumption of alcohol in the European 7.23 In the project on epidemiological Region. It was clear from the evidence research and reporting of drug dependence, presented that there had been a con­ operational tools were tested that should comitant increase in the range of medical meet the data-collecting needs of planners and social problems related to alcohol in developing countries where drug depen­ consumption and the conference unani­ dence is a serious problem. Methodologies mously advocated the promotion of all were established for surveying drug use in known measures for limiting that con­ young people and in the general popula­ sumption. A study by the Regional tion, and for organizing reporting systems, Office is exploring educational programmes including case registers. A method for on alcohol and drug problems, including evaluating treatment in the case of drug smoking. dependence was finalized, in collaboration with investigators in Burma, Malaysia and 7. I 9 In the Western Pacific Region, Pakistan ; it consists of a set of standardized the Government of Papua New Guinea data-collecting forms and software packages in I979 initiated a survey on alcohol for electronic data-processing (tested for consumption and related problems, with use by the WHO collaborating centre in WHO cooperation. Malaysia), which can also be used for the systematic identification of low-cost treat­ ment methods, including indigenous ther­ Prevention and treattllent of dmg dependence apies for use in developing countries.

7.20 In collaboration with UNFDAC 7. 24 A working group on the use of and other international organizations, pro­ laboratory methods in the surveillance and grammes for the assessment, prevention epidemiology of drug dependence (Manila, and treatment of drug dependence as part November I978) underlined the need for of primary health care were under way defining national objectives in epidemio­ during the biennium in Afghanistan, logical research and subsequent measures, Burma, Egypt, Indonesia, Pakistan, Peru carefully selecting the laboratory methods and Thailand. They emphasize an inter­ required, and training staff in laboratory sectoral, multidisciplinary approach in the techniques for drug abuse programmes. case of medicosocial and community­ based methods of treatment. 7.25 The Executive Board (resolution EB63.R29) stressed the need for assessing 7.2I At the end of I979 the network the public health and social consequences of collaborating centres for research and of drug abuse and urged Member States training in drug dependence comprised to cooperate with WHO in developing five institutes, in Canada, Malaysia, Mexico, suitable monitoring instruments. Prep­ Thailand and the United States of America; arations are therefore being made for an two of these institutes also had programmes expert committee to review methodology on alchohol-related problems. for assessing the problems associated with the use of psychotropic substances. 7.22 A review of data on the extent of drug abuse throughout the world was 7.26 The United Nations Commission undertaken in I979, and a study on drug on Narcotic Drugs adopted a number of problems in their sociocultural context, WHO recommendations. Nicocodine was to be used as a basis for policies and pro­ included in the list of drugs in Sched­ gramme planning, was completed. ule III, paragraph I, of the Single Conven- MENTAL HEALTH

don on Narcotic Drugs, I96I; and metha­ ulant and reinforcing properties. It was qualone was transferred from Schedule IV found that (-)cathionine was the main to Schedule II of the Convention on Psy­ pharmacologically active agent, that it chotropic Substances, I97I, on the grounds showed a high degree of reinforcing that it constituted a threat to public health capacity in monkeys, and that it was most in many countries. WHO also recom­ probably responsible for the repeated use mended that tilidine should be subject to of khat. control under Schedule I, dextropropoxy­ phene and mecloqualone under Schedule II, 7.30 In both I978 and I979 WHO and Sufentanil under Schedules I and IV of collaborated with the USSR in organizing the Single Convention ; and that three a travelling seminar on the safe use of analogues of phencyclidine (TCP, PHP psychotropic and narcotic substances. Participants were introduced to the means and PCE) 1 should be controlled under Schedule I of the Convention on Psycho­ by which the safety of using dependence­ tropic Substances. At the request of the producing drugs could be enhanced, with particular reference to the needs of the Commission on Narcotic Drugs, and fur­ developing countries. ther to Article IO of that Convention, WHO's recommendations concerning the cautions or warnings in the leaflet accom­ Training panying retail packages of psychotropic sub­ stances were distributed to Member States. 7. 3 I The training programmes carried out during the biennium focused on (I) 7.27 WHO collaborated with national training in mental health for general authorities in Finland, Madagascar and health personnel, including physicians, Thailand to review the problems and needs public health administrators, nurses and of countries in meeting their responsi­ other primary health care workers; (2) bilities under international instruments for training in public health for mental health the control of the narcotic and psycho­ workers, e.g., in programme planning; tropic drugs. (3) training in specific aspects of mental health work, e.g., biological research 7.28 Research on the dependence po­ methods, the neurosciences, and the ratio­ tential of thebaine, a principal constituent nal use of psychopharmacological drugs ; of Papaver bracteatum and a possible source and (4) training in mental health for of codeine, was finalized and presented to community workers outside the health UNFDAC. Although such potential had sector such as teachers and social welfare long been believed to be minimal, signifi­ workers. Details are given in Chapter I 2, cant dependence was found in studies on paragraphs I2.I02-I2.I09· the rhesus monkey, the possible mechanism of which is being investigated. Biomedical and health practice research 7.29 Following the isolation by the United Nations narcotics laboratory of 7·32 Collaborative studies on mental 30 substances from freshly frozen specimens disorders of major public health signifi­ of khat (Catha edults), pharmacological cance were intensified with a view to investigations were carried out on its stim- advancing knowledge of their causes and sequelae in different societies, and develop­ 1 TCP = r-[1-(z-thienyl)cyclohexyl]piperidine; ing new methods for their prevention and PHP = r-[r-phenylcyclohexyl]pyrrolidine; PCE = N-ethyl-r-phenylcyclohexylamine. control. THE WORK OF WHO, 1978-1979

Biological prychiatry and prychopharmacology tropic drugs in different populations, in which I 2 countries are collaborating, was 7·33 In biological psychiatry and psy­ launched to clarify the efficacy of widely chopharmacology, the search for primary used antidepressant and antipsychotic drugs preventive measures and the improvement accepted as "essential" drugs under the of secondary preventive measures for the Minimal List (e.g., imipramine, amitripty­ control of mental disorders of major line, chlorpromazine). Studies were carried public health importance continued. Dur­ out in various countries on the efficacy ing I978-I979, 38 centres in 28 countries and safety of psychotropic drugs and their were collaborating in I7 WHO-coordi­ optimal dosages, taking into account cli­ nated projects. The participating institu­ matic, cultural and nutritional conditions ; tions, comprising more than 200 scientists, preliminary results indicated that low­ provided the infrastructure for a unique dosage psychotropic drug regimes were type of "international institute" in this possible for the control of the principal field. mental disorders. In emphasis of the "rational treatment" approach to depres­ 7. 34 There were several important find­ sive disorders (one of the most widespread ings during the biennium. For example, groups of mental disorders), an inter­ collaborative research on the biological national symposium on the prevention and basis of mental disorders led to the ten­ treatment of depression was organized, tative identification of new biological with participants from 20 countries markers of schizophrenia and affective (Washington, DC, October I979)· psychoses that could be used in studying high-risk groups. Several studies were 7.36 Information on the efficacy and devoted to elucidating the role of bio­ safety of psychotropic drugs obtained logically active substances (endorphins, from 2 5 collaborating centres is being encephalines) in mental disorders. The analysed and regularly published in the effects of a specific morphine antagonist, Prychopharmacology Bulletin, a publication naloxone, were investigated by collabor­ available in I 5 I countries. A directory ating centres with a view to the control of WHO's long-term experience in col­ of acute and chronic psychotic states. laborative research and training in bio­ The pharmacokinetic properties of one logical psychiatry and psychopharmacology of the most widely used antidepressant was finalized and will be distributed in compounds, amitriptyline, were assessed more than 40 countries. in a multicountry trial, and methods for the routine measurement of the plasma Prychosocial aspects levels of this substance were published. 7·37 At the end of I979, 24 centres in 7. 3 5 Work was undertaken to improve 20 countries 1 were collaborating in a series and rationalize treatment methods for of epidemiological and behavioural studies. psychotic, depressive and neurotic con­ They included investigations on the inci­ ditions. The Minimal List of Drugs for dence of severe psychoses in different the Treatment of Neuropsychiatric Dis­ orders was widely circulated and is being 1 Bulgaria, Canada, Colombia, Czechoslovakia, Den­ used in various centres for administrative mark, Federal Republic of Germany, India, Iran, Ireland, Japan, Netherlands, Nigeria, Philippines, and managerial purposes. A global project Sudan, Switzerland, Turkey, USSR, United Kingdom, on the effects of various dosages of psycho- United States of America, and Yugoslavia. MENTAL HEALTH cultures ; depressive disorders in various ligation as a fertility regulation method, communities ; new approaches to the along with control groups, had been prevention of social impairment and dis­ examined and were being followed up ability ; the influence of stressful life with a view to ascertaining not only the events on mental health and human psychological safety of the method but behaviour ; the role of the family as a also possible positive effects. protective factor in maintaining mental health ; and the relationship between men­ 7·39 A project was initiated to assess tal and physical disease. The preliminary the effectiveness of various types of self­ results of these studies, which entailed the help groups as a form of community detailed assessment of over 2200 patients participation in health promotion and and their families, indicate that : (I) the protection. severity of social impairment and dis­ ability resulting from mental disorders 7.40 The findings of the above research varies considerably according to the com­ were published in monographs and in munity and can be reduced by an environ­ scientific journals. The results of a major ment that encourages and facilitates the WHO-coordinated cross-cultural study, early return of the patient to his normal which demonstrated a better prognosis social role; (2) the capacity of the family for patients with psychotic disorders in and other sources of social support to developing countries as compared with take an active part in prevention or therapy patients in developed countries, were also 1 can be enhanced by specifiable, planned published. interventions; and (3) psychosocial fac­ 7.41 Surveys of prospective longitu­ tors-such as the ability to cope with dinal research in Europe with mental stressful life events, the patterns of emo­ health implications, which can be used tional interaction in the family, and the for assessing the trends of mental mor­ degree of social cohesiveness of the com­ bidity, and also for evaluating the impact munity-are powerful determinants of the of WHO's mental health programme, course and outcome of mental disorders were in press at the end of 1979. and are amenable to specific- trial inter­ ventions. Neurological disorders 7. 3 8 Collaborative research also focused on the assessment of the psychosocial 7.42 The report of the Study Group aspects of public health measures and on the Application of Advances in Neuro­ programmes to improve the quality of sciences for the Control of Neurological life of the family and the community, Disorders 2 was presented to the Executive e.g., family planning programmes. A pro­ Board in January 1979. Work in this ject, coordinated jointly with the Special field concentrated on defining and imple­ Programme of Research, Development and menting appropriate intervention measures Research Training in Human Reproduction, and depended in large measure on the and carried out by field research centres nine WHO collaborating centres for re­ in India, Colombia, Nigeria, the Philip­ search and training in neurosciences. pines and the United Kingdom, is examin­ ing the psychological and social sequelae 1 World Health Organization. Schizophrenia. An international follow-ztp stutfy. Chichester, England, of female sterilization. By the end of 1979 Wiley, 1979· over 6oo women who had chosen tubal 2 WHO Technical Report Series, No. 629, 1978. THE WORK OF WHO, 1978-1979

7·43 The studies being developed for peripheral neuropathies (July I979) was community control programmes in epi­ followed by a study group on the same lepsy-and covering drug therapy, risk subject (October I979)· Field studies were factors in epilepsies, risk factors in cerebro­ being carried out in four Regions : Africa, vascular disorders, neuro-epidemiology, the Americas, South-East Asia and the and peripheral neuropathies-should make Western Pacific. it possible to determine which parts of the world have a particularly high or low 7 ·4 7 Several international symposia incidence of a given neurological disorder, were organized in collaboration with non­ evaluate the effectiveness of present meth­ governmental organizations, the subjects ods of treatment, and forecast the needs including immunopathology of the nervous in programmes and facilities. system ; neurological disorders due to long-term treatment with neuroleptics ; 7 ·44 A study involving a number of the interaction of biological membranes centres is under way for the development with the environment ; the interaction of of "rational treatment" methods for con­ kidney and nervous system ; and headache. vulsive disorders in populations living under different ecological conditions and manifesting different levels of sensitivity Mechanisms for programme develop­ to anticonvulsive drugs. ment and support

7·45 The neurological sequelae of cere­ 7.48 All six regional coordinating brovascular accidents, e.g., paralysis, are groups met during the biennium and by among the major causes of long-term the end of I 979 over zo countries had disability, and research on this subject in formed national coordinating groups for different populations received particular integrated mental health programmes. The attention. Research was also under way membership of national, regional and on the role of such factors as post-infective global groups is intersectoral and multi­ arteritis, parasitic infections, nutritional disciplinary, involving other organizations factors, and neurotransmitters. The data of the United Nations system, nongovern­ obtained were discussed at an international mental organizations, and WHO staff from symposium on cerebrovascular accidents all echelons and from different programmes. sponsored by WHO and the Menarini Foundation (Florence, I978). A booklet 7 ·49 In the African Region, the Mental on the clinical and research classification Health Action Group met in May I978 of cerebrovascular disorders was published and May I 979, and national coordinating in I978. 1 groups were formed in Botswana, Lesotho, Rwanda, Swaziland, United Republic of 7.46 Peripheral nerve diseases are com­ Tanzania, and Zambia. National plans of mon in all parts of the world. The putative action were formulated and are now being etiological factors (genetic, nutritional, implemented. Bilateral agreements, e.g., metabolic, toxic, traumatic, etc.) are diverse between Rwanda and Belgium, and between and their control requires various ap­ the United Republic of Tanzania and proaches. The meeting of a task force on Denmark, were in process of negotiation. Mental health activities were included in 1 World Health Organization. Cerebrovascular the bilateral agreement between Botswana disorders. A clinical and research classification. Geneva, 1978 (WHO Offset Publication No. 43). and Norway. Members of the African

86 MENTAL HEALTH

Regional Expert Panel on Mental Health first regional meeting of national mental met in March 1979. health advisers was held (Federal Republic of Germany, November 1979). 7. 5o The strategies for developing a coordinated mental health programme in 7. 53 At the Regional Office for the the Region of the Americas were estab­ Eastern Mediterranean, the Coordinating lished by a consultative group composed Group Meeting on Mental Health reviewed of representatives of seven countries developments in the Region and made (Colombia, 1978). Costa Rica, Nicaragua recommendations for the next biennium and Venezuela have since formed national (November 1978). coordinating groups on mental health in 7. 54 The Coordinating Group on the which representatives of the health, welfare Mental Health Programme of the Western and education sectors are represented. Pacific Region (April 1979) reviewed WHO's medium-term mental health pro­ 7. 51 The first meeting of an inter­ gramme, underlining the role of the WHO country group on mental health in the collaborating centres, the research being South-East Asia Region (December 1977) carried out, and the psychosocial factors provided a stimulus for developments encountered in the Region ; and analysed during 1978-1979· The group met again the scope and role of national coordinating in March 1979 to review developments groups. and practices in mental health services, including training and research. Recom­ 7. 5 5 These national and regional con­ mendations on policy and programme sultations were followed by the third were put forward. Bangladesh, Burma, meeting of the Coordinating Group for Sri Lanka and Thailand all established the WHO Mental Health Programme intersectoral, multidisciplinary coordinat­ (Alexandria, September 1979), which ing or advisory groups at ministerial or enabled representatives of all coordinating government level for mental health or groups and WHO staff to review tha,t drug dependence. programme in the context of "Health for all by the year 2ooo" ; decide what 7. 52 In the European Region, in addi­ activities should be undertaken in the tion to meetings of the Consultative next biennium ; and agree on the specific Committee for the European Mental Health steps to be taken in formulating the mental Programme (May 1978) and the Technical health section of the Seventh General Advisory Committee (February 1979), the Programme of Work. Chapter 8

Prophylactic) Diagnostic and Therapeutic Substances

Drug policies and management sale and distribution of drugs and bio­ logicals in order to ensure the availability 8.1 THE REORIENTATION of of appropriate drugs at all levels of the WHO's programme on drugs in health care system. The reoriented pro­ response to Health Assembly gramme is consonant with these recom­ resolution WHAz8.66 (1975) focused atten­ mendations and with the strategies to tion on the problems of relating the supply achieve health for all by the year zooo. of pharmaceuticals to health needs at the global, regional and country level. The 8.3 During 1978-1979 global, regional 2 Technical Discussions of the Thirty-first and country studies were undertaken in World Health Assembly-whose subject collaboration with Member States, and was "National policies and practices in seminars, workshops and meetings were regard to medicinal products ; and related organized to promote and formulate com­ international problems"-served to under­ prehensive national drug policies. A num­ score the difficulties.1 The programme on ber of problems common to all developing drug policies and management has followed countries emerged. They were : ( 1) the the directives in resolutions EB6I.RI7, inability of countries to meet the demand WHA31·32 and WHA32.41, which inter alia for drugs, particularly those required for requested the Organization "to cooperate primary health care; (z) the need for with Member States in formulating drug assessing requirements in drugs at different policies and management programmes that levels (particularly the primary health care are relevant to the health needs of popula­ level) and strengthening the potential for tions and are aimed at ensuring access of local manufacture; (3) the need for ratio­ the whole population to essential drugs nalizing procurement and utilization by at a cost the country can afford". making a selection of drugs and adopting national formularies (lists of essential 8.z The International Conference on drugs) ; (4) the inadequacy of distribution Primary Health Care (Alma-Ata, 1978) and storage facilities, particularly in rural also recognized the crucial need for essential areas; (5) the shortage of personnel trained drugs for primary health care and recom­ for management and for technical work at mended that governments should formulate all levels; (6) the inadequacy of facilities national policies and regulations with for proper quality control; and (7) the respect to the import, local production, 2 World Health Organization. National drug policies. 1 See Chapter 1, paragraph 1.12. Copenhagen, 1979 (Public Health in Europe, No. 12).

88 PROPHYLACTIC, DIAGNOSTIC AND THERAPEUTIC SUBSTANCES need for reviewing, and where necessary industry and establish the necessary mecha­ revising, drug legislation and regulatory nisms. Meetings were held to acquaint control. Member governments with significant de­ velopments in drug control within the 8.4 Feasibility studies, some with the Region. financial support of UNDP, were under­ taken in several Member States with a 8.8 In the South-East Asia Region the view to establishing national drug policies Technical Discussions at the I979 Regional and strengthening the local formulation Committee were devoted to "Drug policy, of essential drugs. At the end of I979 including traditional medicine, in the con­ guidelines and recommendations on the text of primary heal·-h care". Most coun­ establishing of low-cost formulation plant tries in this Region have by now prepared for essential drugs in developing countries lists of the essential drugs needed for were prepared. primary health care, and many existing or 8. 5 Guidelines on other aspects of projected units of pharmaceutical produc­ tion are aiming at achieving selfreliance. national drug policies-including procure­ ment, distribution and quality assurance­ 8.9 The Regional Office for Europe in were also planned, which should be instru­ April I 979 established a new unit of mental in advancing country programming prophylactic, diagnostic and therapeutic in the field of drugs. substances to stimulate research on drug 8.6 The subject of drug policies and utilization and assist in formulating national management received similar attention at drug policies. Studies on drug evaluation 1 regional level, where a number of pro­ and drug utilization were undertaken, grammes were formulated. In the African and are being expanded. Region, an Expert Committee on Drug 8.Io In the Eastern Mediterranean Re­ Policies and Management was convened gion, several projects were implemented in I978. Studies with a view to local in various countries and the Region is production, establishment of subregional expanding its activities in relation to quality control laboratories, distribution, procurement of drugs, administration and and joint purchasing of essential drugs control, pharmaceutical inspection, regis­ were initiated. Preparations were being tration, dissemination and control of made for a subregional meeting on co­ information, and manpower development. operation in drug policies and management. Studies on drug utilization were in progress 8.7 At the Technical Discussions at the in some countries of the Region. Regional Committee for the Americas 8. I I In the Western Pacific Region a in I978, which had as their subject "The working group reviewed regional aspects impact of drugs on health costs : national of drug policies and management (March and international problems", the need for I978), identified priority areas for con­ comprehensive national drug policies was sideration, and laid the basis for a medium­ emphasized. To support the local and term programme. regional programmes that should result from such policies, contact was established 8. I z Technical cooperation in this field with the Latin American Federation of among developing countries began in I978 in the Pharmaceutical Industry (FIFARMA) 1 to define the areas of cooperation between World Health Organization. Studies in drug util­ ization: Methods and application. Copenhagen, 1979 the public sector and the pharmaceutical (WHO Regional Publications, European Series, No. 8). THE WORK OF WHO, 1978-1979 the South Pacific countries, which adopted the public sector of health services of the a common list of essential drugs. In 1979 least developed countries. It established a task force and subsequent working groups an Ad Hoc Committee on Drug Policies, outlined the role, organization, location whose proposals for an action programme and financing of four proposed components were subsequently endorsed by the Health of a South Pacific pharmaceutical service, Assembly (resolution WHA3J.32). More namely: a joint purchasing office, a ware­ than 30 governments have expressed in­ house for centralizing the reception, storage terest in participating in consultations and and distribution of drugs purchased, a negotiations for the proposed action pro­ quality assurance unit, and a drug infor­ gramme and designated representatives for mation service. The political and technical this purpose. implications of the programme were con­ 8.14 The report of the Expert Com­ sidered at a Conference of Ministers of mittee was enthusiastically received in Health of the South Pacific Areas (Manila, Member States and has served as both an November 1979). The Association of impetus and a guide for countries drawing South-East Asian Nations (ASEAN) also up their own national lists. A second met in November 1979 to discuss technical expert committee (July 1979) reviewed the cooperation in drug legislation, evaluation, first list of essential drugs and considered and quality assurance ; problem areas the commonly used dosage forms for each were identified and the activities that drug appearing in the revised list. 2 Infor­ should make up the technical cooperation mation sheets on the proper use of the drugs programme were agreed upon. In the were further discussed, and methods are Caribbean area, the development of a being explored to present them in a format subregional pharmaceutical policy was useful for developing countries. strengthened by the establishment of a Caribbean Regional Drug Testing Labo­ 8.15 Three meetings were held with ratory for the microbiological and pharma­ the pharmaceutical industry during 1979 cological analysis of drugs obtained by the and many major drug manufacturers individual governments or through the pledged their collaboration in furnishing bulk-purchasing schemes sponsored by the governments of the least developed the Caribbean Community (CARICOM). countries, on specially favourable con­ ditions, with selected products needed to Selection of essential drugs extend and improve health care coverage in the public sector. 8.13 In January 1978, the Executive Board praised the report of the Expert Use ~f medicinal plants Committee on the Selection of Essential 8.16 The use of natural resources, Drugs 1 and called for an action programme particularly medicinal plants, is an aspect on technical cooperation in that area of drug policies and management that is (resolution EB6I.RJ7). The Board parti­ of great moment to many developing cularly emphasized the importance of countries. At global level, general guide­ dialogue and collaboration with private lines for the selection and characterization and State-owned pharmaceutical companies of medicinal plants are being developed. to make essential drugs available on favourable conditions for exclusive use in 2 WHO Technical Report Series, No. 641, 1979 (Selection of essential drttgs. Second report of the WHO 1 WHO Technical Report Series, No. 615, 1977· expert committee). PROPHYLACTIC, DIAGNOSTIC AND THERAPEUTIC SUBSTANCES

Interagenry collaboration drug control laboratories. In the Region of the Americas the development of 8. I 7 Close contacts were maintained laboratory capabilities in the drug field with UNICEF, UNIDO, UNCTAD and was strengthened by the establishment of other organizations of the United Nations the Caribbean Regional Drug Testing system which, under their terms of refer­ Laboratory described in paragraph 8. I 2 ence, have activities related to essential above. In the South-East Asia Region a drugs. With the financial support of regional seminar on drug quality control UNDP, a United Nations interagency task was held in New Delhi (January I978). force on economic and technical cooper­ The emphasis in the countries of the ation among developing countries in the Region was on training specialists in drug pharmaceutical sector carried out country quality control and strengthening govern­ surveys in I 978 to determine the most mental drug control laboratories. In the serious problems arising in connexion European Region a review of training with the supply of pharmaceuticals. The programmes for pharmacists was initiated. Government of Guyana, on behalf of the The development of national drug quality non-aligned countries, acted as coordinator assurance systems in the Eastern Mediter­ for the project, which was carried out ranean Region was promoted by providing with the cooperation of the United Na­ specialists for national drug control labo­ tions Department of Technical Cooperation ratories, awarding fellowships, and sending for Development, UNCTAD, UNIDO, trainees from countries of the Region to and WHO. The report on the project, the courses on pharmaceutical inspection "Pharmaceuticals in the developing world­ held in the Federal Republic of Germany. Policies on drugs, trade and production", In the Western Pacific Region a number was issued in I979· of countries were visited by a special task force and as a result proposals were made Pharmaceuticals for a joint South Pacific pharmaceutical service, which would include a joint drug 8.I8 WHO increased its activities to quality control laboratory (see paragraph improve the quality of drugs, the main 8.I2 above). Since lack of resources effort being directed towards essential drugs prevents many developing countries from used in developing countries where tech­ introducing a comprehensive system of nical facilities for the full quality assess­ drug quality assurance, the WHO Expert ment of manufactured or imported pharma­ Committee on Specifications for Pharma­ ceutical products are rare. ceutical Preparations (November I979) 1 made recommendations for priority action 8.I9 Quality assurance in pharmaceu­ that could be taken by health authorities tical supply systems is an important establishing or expanding their national element of national programmes on regu­ quality control systems. latory control of drugs, and is designed to prevent the manufacture, importation and 8.20 The certification scheme on the distribution of low...:quality, noneffective, quality of pharmaceutical products moving or harmful drugs. During the biennium in international commerce, a revised text WHO directed its work towards streng­ of whicli was adopted in I975 by the thening national capabilities in this area. Twenty-eighth World Health Assembly In the African Region a study began on 1 Report to be published in the WHO Technical the possibilities of setting up regional Report series in 1980. THE WORK OF WHO, 1978-1979

(resolution WHA28.65), is a mechanism by quality assurance (Fiji, December I979) which the health authorities of a developing dealt with the practical application of the country that is importing a drug can tests evolved so far, especially as regards receive a certificate from the health author­ drugs purchased for use in organized health ities of the exporting country stating that services. the product is authorized for sale in the 8.23 The revision of the International exporting country and that the manufac­ Pharmacopoeia continued. The process was turer is subject to regular inspection. completed for Volume I, which covers During the period I978-I979, a further general methods of drug analysis, and the 28 Member States joined the scheme and third edition of that volume was published designated responsible national authorities, at the end of I979.2 The revision of bringing to 54 the total number of par­ monographs for substances essential for ticipating countries. A supplementary list primary health care continued, with the of participating Member States was pub­ help of members of the WHO Expert lished.1 Advisory Panel on the International Phar­ 8.2I The WHO recommendation on macopoeia and Pharmaceutical Prepara­ good practices in the manufacture and tions and of specialists from national quality control of drugs (resolution pharmacopoeia commissions. Draft mono­ WHA28.65) continued to influence the graphs for some I 20 substances were pharmaceutical regulations of most drug­ under review at the end of I 979· producing countries, including those that 8.24 The WHO collaborating centre for are major exporters to developing coun­ chemical reference substances, Sweden, tries. These recommendations concern continued to maintain and distribute inter­ the ways of carrying out the manufacturing national reference material for pharma­ and the control procedures that affect the ceuticals needed for the analytical methods quality of drugs at the production stage. of the International Pharmacopoeia. In During the biennium the question of I978-I979 the centre provided annually in-process quality control of dosage forms more than 28oo packages of reference produced in developing countries was substances to governmental and industrial evaluated with a view to extension of the drug control laboratories in over 50 Mem­ relevant "good practices" recommenda­ ber States. Seven new reference substances tions. were established, bringing to 8 I the total number maintained at the centre. One of 8.22 The development of procedures for basic tests for drugs continued. The the ways of satisfying the increasing need of developing countries for reference sub­ procedures established for some 200 essen­ tial pharmaceutical substances were the stances for the most widely used essential object of field studies, and work began drugs is to arrange for regional reference on simple dosage forms containing those materials to be available. This was dis­ substances. The basic tests are primarily cussed at a workshop on reference materials designed to confirm the identity of the for Latin America (Brazil, October I979) pharmaceutical product and to ensure that and possible solutions were recommended, gross deterioration has not occurred along in the context of technical cooperation the distribution chain. In the Western among developing countries. Pacific Region a workshop on drug 2 World Health Organization. The International Pharmacopoeia, 3rd ed., Volume 1 (General methods 1 See WHO Chronicle, 33: 289-294 (1979). i fiEJ of analysis). Geneva, 1979· PROPHYLACTIC, DIAGNOSTIC AND THERAPEUTIC SUBSTANCES

8.25 New international nonproprietary Government of the Federal Republic of names for pharmaceutical substances were Germany, continued in 1978 and 1979· selected on the basis of requests by national A considerable amount of research on nomenclature authorities and by pharma­ patterns of drug utilization has been ceutical manufacturers. During the bien­ stimulated as a result of programmes nium new names were proposed for 323 developed in this Regional Office. substances, bringing to 41 55 the total number of nonproprietary names so far Biologicals established by WHO. 8.29 It is now three years since govern­ 8.26 A quarterly WHO bulletin, Drug ments and regional offices were informed Information, has become established as a that training in the quality control of vehicle for prompt and direct exchange of biologicals would receive the financial information on drug safety and efficacy. assistance of UNDP. Since then, seven It is of prime importance for all drug candidates have been trained and a further regulatory authorities to be in touch with four are in training-but this is a very current issues of international concern. disappointing response. Either the import­ The rapid evolution of drug epidemiology, ance of using biologicals known to be and the obligation of many national safe and effective is not appreciated, or authorities to review all currently available there are not enough people with a suitable drugs within their jurisdiction, creates an background for this specialist training. important measure of interdependence ; An analysis of the problem will be made this is accentuated by the fact that the with a view to stimulating the establish­ complex multidisciplinary assessments re­ ment of national quality control. It is quired to resolve many drug-safety issues clear however that this is an area where can tax the technical and financial resources technical cooperation is greatly needed : of even the most economically developed when vaccines prepared in the developing nations. The call for more information world are tested for safety and potency by of the type required for the. evaluation and an independent laboratory it is not un­ licensing of medicines was reflected at common to find that they do not meet the regional level, particularly in the pro­ WHO requirements. And it is important grammes of three Regions-the Americas, to emphasize that communicable diseases Europe, and the Eastern Mediterranean. will not be brought under control unless 8.27 The WHO collaborating centre safe and potent vaccines reach the majority on international drug monitoring, Uppsala, of the target population. Sweden, assumed responsibility for the 8.30 On the other hand, the three-week operational aspects of the programme for refresher courses in the quality control of monitoring of adverse reactions to drugs measles and poliomyelitis vaccines were in March 1978. WHO headquarters well attended. In 1978-1979 such courses retained responsibility for policy coordina­ were held in Argentina, Australia, France, tion, participation of national and other India, Mexico and the United Kingdom. centres, and dissemination of information. They are intended for scientists already working in the quality control of vaccines. 8.28 The series of annual symposia on clinical pharmacological evaluation in drug 8.31 The research programme to im­ control, organized by the Regional Office prove the stability of measles and polio­ for Europe in collaboration with the myelitis vaccines made good progress.

93 THE WORK OF WHO, 1978-1979

Some of the pharmaceutical companies to adapt them to the latest findings. producing low-stability measles vaccine, The programme places emphasis on the when presented with the evidence that vaccines used in immunization program­ there was a marked difference in stability mes, and the requirements for diphtheria among their products and that only high­ toxoid, tetanus toxoid, pertussis vaccine stability vaccines are suitable for use in and dried BCG vaccine were therefore countries with high ambient temperatures, revised. 2 Manuals covering the production took steps to improve their products. of these vaccines were brought up to date As regards the improvement of pertussis and distributed widely. vaccine, the amount of research being 8. 34 Since the establishment of the carried out has never been so great. "Requirements for the procurement, pro­ The WHO programme, with UNDP sup­ cessing and control of blood products port, is stimulating the development of and related substances", a programme has more potent and less toxic vaccines.' been initiated in this area supported by 8.32 The establishment of new inter­ extrabudgetary resources. With the assist­ national standards and reference prepara­ ance of the regional offices a panel of tions continued for all biologicals. In the experts was established, and a review was two-year period, international reference made of potential needs. Emphasis will materials were established for three anti­ be placed on fractionation techniques for biotics, one antibody, four antigens, six plasma and on the quality control of the blood products or related substances, fractions. seven endocrinological or related sub­ 8.35 Work continued under the pro­ stances, nine reagents, and five miscella­ gramme on the production and control neous substances. These reference materials of oral poliomyelitis vaccine, assistance are particularly important, since the first with their national production being given requirement of a research programme is a to India and Mexico. There is a current common standard for comparison of data shortage of this vaccine in the world, and between laboratories, countries and con­ the programme will continue for some tinents. To some countries struggling to years. The trend in certain countries meet their basic needs, much of the new towards reconsidering the use of killed research may appear to be exotic, but poliomyelitis vaccine was recognized, and today's research findings in the developed the WHO requirements for this type of world will be needed by the developing vaccine were revised. world tomorrow (this was true of the standards for vaccines and antibiotics and 8.36 The increase in national legisla­ is becoming equally true for hormones tion on the control of biologicals has led and blood products). It is interesting to to WHO being requested to formulate note that in 1978 and 1979 more than half international requirements to ensure that of the thousands of international reference a common standard is applied in all materials that were issued went to the countries. Such requirements are needed, developing countries. for example, in the quality control of anti tumour antibiotics ; hepatitis vaccines; 8.33 In addition to the establishment and quality assurance of reagents and kits of reference materials, the requirements used in pregnancy tests. for some biological substances were revised 2 WHO Technical Report Series, No. 638, 1979, 1 See also Chapter 9, paragraph 9.209. pp. 37-147·

94 PROPHYLACTIC, DIAGNOSTIC AND THERAPEUTIC SUBSTANCES

8.37 To promote local production of validity of the guidelines began in Algeria, vaccines in the context of technical co­ and preparations were made for similar operation among developing countries and studies in other countries. A particular to strengthen the quality control of such aspect is evaluation of the cost and use­ vaccines, the Regional Office for Africa fulness of the laboratories in relation both organized a consultation of directors of to individual health care and to public centres for the production and quality health. Further technical guidelines for control of vaccines (April 1979) ; six peripheral laboratories were in prepara­ countries took part. The main recom­ tion at the end of the biennium, to cover mendations made were for : an inventory the collection of specimens and their of regional laboratories and their pro­ despatch to immediate referral laboratories, duction potential, with a view to estab­ the maintenance and repair of equipment lishing independent networks ; and the at this level, and the training of staff. orientation of present production capacity Two documents were prepared in collabo­ towards vaccines recognized as priority, ration with the League of Red Cross support to applied research on such vac­ Societies : on the organization of blood cines, as well as the development of a transfusion services at the peripheral level ; coherent policy for the training of personnel and on the production of blood-grouping at regional, subregional, national and reagents. institutional level. 8.40 Cooperation was given in the strengthening of public health and other Health laboratory technology referral activities at intermediate and central 8.38 In line with resolution WHA29.74, level and in the management of health which inter alia requested the Director­ laboratories. In countries of the South­ General to develop a programme of health East Asia Region particularly, priority was technology relating to primary health care given to expertise in disease surveillance and rural development, emphasis during and emphasis was placed on laboratory 1978-1979 was placed on the promotion, diagnosis of dengue, Japanese encephalitis) in all regions, of peripheral health labo­ diarrhoeal diseases, malaria, and filariasis. ratory services in support of more effective Cooperation also covered the development rural health care, particular attention being of public health laboratories at different given in the Eastern Mediterranean Region levels in Algeria ; national blood transfusion to the public health aspects. There was a services based on voluntary non-remu­ favourable response to the policy in many nerated donation of blood, particularly in countries : in Viet Nam, for example, a the Eastern Mediterranean Region and the network of So peripheral laboratories was Region of the Americas ; the establishment established. of a clinical toxicology unit and training of staff in Malta ; the setting up of a 8.39 Guidelines on the organization quality control programme in clinical and operation of such laboratories in chemistry in Portugal ; and the assignment support of preventive, curative and pro­ of long-term staff to the health laboratory motive services for both the community services of Fiji, Papua New Guinea, and and the individual were published in the Tonga. form of a document entitled, "Laboratory services at primary health care level". 8·4 1 The emphasis on appropriate tech­ Field operational studies to assess the nology in laboratory practice includes the

95 THE WORK OF WHO, 1978-1979 promotion of simple, inexpensive but courses on identification of enterobacteria reliable equipment, particularly for periph­ and on quality control were held in Ban­ eral laboratories. During the biennium, a gladesh, Jordan, Kenya, and Morocco ; consultation at WHO headquarters iden­ and a course on diagnosis of the most tified areas for development and research frequent pathogenic bacteria took place and recommended that particular attention in the Philippines. In the South-East should be given to local production or Asia Region, there :were intercountry assembly of such equipment. workshops in immunohaematology, food microbiology and immunology ; training 8.42 National production and control was also given in laboratory management of reagents was similarly promoted, par­ and evaluation and in microbiology. ticularly in the Region of the Americas. Courses on quality control in clinical Cooperation was initiated with several chemistry were held in Argentina, Iraq countries for the establishment of centres and Malaysia for trainees from the Americas, for this work. the Eastern Mediterranean, and the South­ East AsiafWestern Pacific Regions respect­ 8.43 The containment of costs and the ively. In Africa, workshops on the develop­ optimal use of laboratories are universal ment of blood transfusion services were problems. A working group organized by held in conjunction with the League of the Regional Office for Europe (London, Red Cross Societies-in Bujumbura for September 1979) reviewed rational and French-speaking countries and in Nairobi economical technologies available for for English-speaking countries. various laboratory disciplines. 8.46 National courses were held in 8.44 Many countries are now under­ many countries, including Argentina taking the training of laboratory staff to (identification of enterobacteria), Egypt meet local needs, in particular the prepara­ (virology), Jamaica (diagnosis of mycotic tion of technician instructors to train infections), Malaysia (laboratory methods peripheral laboratory workers. By the end in blood transfusion), Philippines (labo­ of the biennium facilities were increasingly ratory management), and Viet Nam (bac­ available at national level. Thus, in the teriology, blood transfusion and haema­ Eastern Mediterranean Region, laboratory tology). In Papua New Guinea, a third assistants were being trained in almost all group of laboratory assistants for peripheral countries, technicians were being trained laboratories attended a one-year course. in 90% of them, and university courses Other countries in the Western Pacific leading to a degree in medical laboratory Region were considering introducing the technology were open to students in same type of training, and some progress Lebanon, Sudan, and Yemen. In the was noted in Laos. Americas, regional centres were being selected for training personnel in micro­ 8.47 Documents published or in prep­ biology, laboratory administration, and aration, and intended for training purposes maintenance and repair of equipment. as well as for use in intermediate labora­ tories, covered simplified procedures for 8.45 Training courses in various labo­ the isolation and identification of enteric ratory disciplines laid emphasis on sim­ pathogenic bacteria; quality control in plified, inexpensive methodology and qual­ clinical chemistry ; fundamental diagnostic ity control. Regional or intercountry laboratory haematology as related to the PROPHYLACTIC, DIAGNOSTIC AND THERAPUETIC SUBSTANCES anaemias ; and a manual of routine methods grammes in clinical chemistry and haema­ in clinical chemistry. In collaboration with tology were started in several countries, the League of Red Cross Societies, an including India, Indonesia and Thailand. addendum was published to the book, Specifications were published for salmo­ Blood Transfusion : a Guide to the Formation nella polyvalent agglutination sera and for and Operation of a Transfusion Service. 1 streptococcus grouping sera ; and inter­ national reference sera with assigned values 8.48 In the programme for standardiza­ for a number of constituents were estab­ tion of materials and methods, WHO­ lished for use in clinical chemistry. Inter­ sponsored quality control projects in micro­ national reference methods were agreed biology, haematology, clinical chemistry upon for the rubella haemagglutination and blood group serology were in opera­ inhibition test and the histoplasmosis tion ; and national quality control pro- micro-immunodiffusion test. Guidelines on methods for determination of the haemoglobin content of blood, of packed 1 Cazal, P. & Maycock, W. d'A. Blood transfusion, Addendum I9l8. Geneva, World Health Organization, cell volume, and of the erythrocyte sedi­ 1978. mentation rate, were prepared.

97 Chapter .9

Communicable Disease Prevention and Control

9·I ONLY SOME I2 years ago small­ social relevance to this and future genera­ pox was endemic in 33 countries tions. with a total population of I 200 ooo ooo; and I 2 other countries had imported cases. The entire world was Epidemiological surveillance still at risk. Now smallpox transmission has ceased throughout the world, signifi­ 9· 3 The basis of the remarkably ef­ cantly during the International Year of the fective system instituted for smallpox Child. This history over a deadly disease eradication was unrelaxing epidemiological was brought about through national com­ surveillance and the organization of con­ mitment everywhree and effective inter­ tainment measures. The application of national cooperation. It is a step towards epidemiological methods guides public a better standard of health for all the people health administrators in deciding on the of the world. most effective and feasible strategies for communicable disease control within the 9.2 Nevertheless, much remains to be social and operational constraints imposed done in communicable disease prevention on them. and control. Malaria, the acute diarrhoeal and respiratory infections, childhood in­ 9·4 Inadequate epidemiological services fections, tuberculosis, preventable blind­ and the shortage of trained epidemiologists ness, and other endemic and epidemic in most countries remain the weakest com­ diseases continue to contribute heavily to ponent of communicable disease control unacceptably high levels of mortality and programmes. They give rise to insufficient morbidity and impaired quality of life in evaluation, lack of responsibility and, most developing countries. The Sixth consequently, chronically poor manage­ General Programme of Work focuses on ment. In all regions efforts are being made practical approaches that should reduce to relate training to the functions the significantly in any country the heavy personnel should perform in a national burden of communicable diseases, par­ epidemiological service. In cooperation ticularly in children under five, through with national health administrations, greater the application of knowledge and well­ emphasis was placed on training relevant tested technology. Primary health care, to conditions in the country. An assess­ in fact, presupposes a determined attack ment is accordingly being made of the on such problems, which are of major manpower needs of existing epidemio- COMMUNICABLE DISEASE PREVENTION AND CONTROL

logical services and training facilities, so and emergency action ; prepared a guide that the latter should meet the needs of on emergency action in laboratory and the health services, adopting a problem­ transport-associated accidents ; 1 and drew oriented, learning-by-doing approach linked up m1mmum standards of laboratory with an ongoing communicable disease safety. 2 control programme, an outbreak of disease, or a research project in the laboratory or 9.8 With the Giovanni Lorenzini Foun­ in the field. dation WHO had cosponsored in 1978 an international symposium on genetic engi­ 9·5 Health authorities are being en­ neering. In 1979 it organized an inter­ couraged to re-examine vaccination cer­ national consultation on the management tificate requirements for international travel of emergencies caused by "unusual" in the light of the epidemiological situation diseases. It collaborated with the Universal of the diseases subject to the International Postal Union and the International Air Health Regulations. The certification on Transport Association in the revision of 26 October 1979 of the last known endemic the regulations for the international ship­ countries as smallpox-free will accelerate ment of biological specimens and materials. the disappearance of the smallpox vaccina­ tion certificate as a requirement for trav­ ellers. Smallpox eradication

9·9 Only two cases of smallpox were Safety measures in microbiology reported to WHO during 1978 and 1979. They occurred in August and September 9.6 Much public concern has been 1978 in the United Kingdom, in a labo­ expressed recently about the hazards of ratory holding stocks of variola virus. new research on pathogenic micro­ The last case recorded elsewhere, in Oc­ organisms. Several tragic laboratory ac­ tober 1977 in Somalia, remains the last cidents have occurred. New pathogens known case of endemic smallpox in the of great virulence have been discovered, world. and old pathogens have re-emerged in epidemic form. The dangers call for the Certification of eradication strengthening of safety precautions in diagnostic and research laboratories, in 9.10 In October 1977, 79 countries the transfer of specimens and other bio­ still required special procedures prior to logical products between laboratories, and being certified as smallpox-free. With the in the management of communicable approval of. the World Health Assembly diseases. in 1978, a Global Commission consisting of I 9 international experts was established 9·7 WHO therefore established a spe­ to monitor these procedures and the certifi­ cial programme on safety measures in cation process. By the beginning of 1978, microbiology at the beginning of 1979. 4 5 of the 79 countries had been visited by During the rest of the year, with the international commissions that had cer­ financial support of several countries, it tified that smallpox had been eradicated. established a classification of microorgan­ isms by risk; 1 started developing inter­ 1 Week[)! Epidemiological Record, :zo: 154-156 (1979). national guidelines on laboratory safety 2 Week[)! Epidemiological Record, 44: 340-342 (1979).

99 THE WORK OF WHO, 1978-1979

During I978 and I979 the remaining the Horn of Africa ; over 5o ooo cases of 34 countries were also certified. rash with fever were detected and investi­ gated and almost 8ooo laboratory specimens 9· I I The principal criterion for eradi­ were collected during I978 and I979· cation (as defined by the WHO Expert In no case was smallpox diagnosed. From Committee on Smallpox Eradication in countries in other parts of the world its second report 1) was evidence of no already considered as smallpox-free, a reported case of smallpox for at least two total of I04 rumours of smallpox were years despite surveillance sufficiently sensi­ received ; investigations by government tive to have detected such cases had they or WHO teams or both excluded a diag­ occurred. All the available evidence was nosis of smallpox in every case. WHO will reviewed for each country either by a collaborate with any government requiring visiting international commission or by a assistance in the investigation of suspected special visit and/or submission of a detailed smallpox cases, and the laboratory service report to the Global Commission. provided by WHO collaborating centres 9· I 2 As the last foci of endemic small­ will remain available. pox were in the Horn of Africa, assessment of this area was particularly emphasized. Variola vims in laboratories Independent international comm1ss10ns involving a total of 20 experts were con­ 9· I 5 At the beginning of I 978 at least vened in Djibouti, Ethiopia, Kenya, and I 6 laboratories kept samples of variola Somalia, each meeting lasting Io-zo days. virus strains. WHO efforts to reduce this A final meeting was held in Nairobi to number to a minimum met with good consider the findings in all these countries, cooperation and at the end of I979 only as their links through common nomadic seven laboratories still kept variola virus populations are of epidemiological im­ (Table 9.I). Representatives from all the portance. It was concluded that the laboratories retaining variola virus and extensive surveillance programmes in these associated national control authorities met countries during I978 and I979 had, in Geneva (April I979) to discuss ways of indeed, been sufficiently sensitive ; no assuring the maximum security for these smallpox had been reported. Certification of smallpox eradication in the Horn of Table 9.1 Laboratories retaining variola virus as at 28 September 1979 Africa was announced by the Director­ General on 26 October I979· Laboratory City/country

9· I 3 At its meeting in December I 979, 1. Center for Disease Control the Global Commission concluded that (CDC) • Atlanta, Georgia, USA 2. Institute for the Control of smallpox had been eradicated throughout Drugs and Biological Pro- the world and that there was no evidence ducts Beijing (Peking), China 3. National Institute of Virology Sandringham, South suggesting that it would return as an Africa 4. Research Institute of Virus endemic disease. Preparations • Moscow, USSR 5. Rijks lnstituut voor de Volks- Surveillance gezondheid • Bilthoven, Netherlands 6. St Mary's Hospital Medical London, School • United Kingdom 9· I4 Extensive surveillance program­ 7. United States Army Medical Research Institute for In- Frederick, mes were carried out in the countries of factious Diseases Maryland, USA

1 WHO Technical Report Series, No. 493, 1972. • WHO collaborating centre.

IOO COMMUNICABLE DISEASE PREVENTION AND CONTROL

strains. The laboratories will continue to Vaccination poliry be inspected periodically by teams of experts convened by WHO. 9.19 Progress was. made in changing the requirements for smallpox vaccination certificates from travellers. At the end Poxvirus research of 1979 only 32 countries still required such certificates from travellers, compared 9.16 Various consultations were held with 100 at the end of 1977. On the other during the period on research into ortho­ hand, routine smallpox vaccination has not poxviruses. The main purpose of this research is to confirm that there is no been so widely discontinued ; at the end of animal reservoir of smallpox. Particular 1979 it was no longer obligatory in only 51 attention was focused on the use of genome countries (Figure 9· I). The Global Com­ mapping for the differentiation of ortho­ mission, in its final report, recommended poxviruses and a research schedule was cessation of all smallpox vaccination except for investigators at special risk. drawn up. It is possible that, following thorough characterization of the DNA of 9.20 While there is no scientific evidence various strains of variola virus, retention to suggest that smallpox might recur, of the virus itself for reference purposes WHO has taken steps to ensure that any may not be essential. future smallpox alert can be adequately dealt with by maintaining an effective 9.17 In June and July 1979 a Zaire/ surveillance mechanism. WHO collabo­ CDC/WHO team carried out research in rating centres will continue to provide the Equateur Province of Zaire, where a diagnostic services, and further research number of human monkeypox cases have will be carried out on orthopoxviruses. been detected, to define further the natural Reserve stocks of vaccine are being accu­ history of monkeypox and whitepox mulated for long-term storage in Geneva viruses. Paired specimens (blood and and New Delhi, and its continued potency organ tissues) from more than 90 species will be confirmed by periodic testing. of African mammals were collected for identification of poxviruses by serology and culture; and about 500 serum speci­ Malaria mens were collected from unvaccinated persons living in monkeypox-infected areas, 9.21 Following the dramatic resurgence to be tested for evidence of prior monkey­ of malaria, particularly in South-East Asia pox infection. and in Turkey, the disease now shows a downward trend ; but the general epidemio­ 9.18 In 1978 and 1979, 17 cases of logical situation still causes concern, es­ human monkeypox were reported from pecially as many of the technical, financial, Zaire and one case from Benin, the latter and administrative problems responsible originating in Nigeria. A total of 46 cases for the worsening of the situation during of this disease have been detected since the past decade are far from being solved. 1970, when it was first identified in Zaire. A programme to continue surveillance for 9.22 The Thirty-first World Health monkeypox from 1980 to 1985 was sup­ Assembly endorsed a new malaria control ported by the Global Commission and strategy (resolution WHA3J.45), in pur­ endorsed by the Thirty-second World suance of which a number of actions have Health Assembly. been taken at all levels of the Organization.

IOI

COMMUNICABLE DISEASE PREVENTION AND CONTROL pation of other islands of the Indian Ocean, technical problems. In Indonesia (Java the aim being to prevent the reintroduction and Bali), Nepal, and Thailand the incidence of malaria into the islands. of malaria has continued to show an upward trend in recent years. The situa­ 9.25 In the Region of the Americas tion remains critical in all countries of the no substantial progress was observed in region because, in addition to the already the malaria eradication programmes. well-known obstacles to control, P. jalci­ Twelve countries or areas comprising parum strains resistant to the 4-amino­ about one-third of the population origi­ quinolines are spreading. A large pro­ nally at risk remained malaria-free and in gramme for their containment was launched eight the risk was kept to negligible levels ; in the north-eastern states and the states but the continuous influx of imported of Orissa and Bihar in India, with the cases, the reduction in antimalaria measures, technical cooperation of SIDA and WHO. and increased technical problems in areas of high receptivity have in some instances 9.27 In the European Region the num­ led to a rapid re-establishment of trans­ ber of cases remains very low in Algeria mission. In another five countries where and Morocco, where extensive antimalaria malaria is localized slow progress is being measures are being continuously carried made. In most of the remaining countries out. Considerable improvement is reported (Bolivia, Colombia, El Salvador, Guate­ in south-eastern Turkey, where the malaria mala, Haiti, Honduras, Nicaragua, and epidemic, which is associated with agri­ Peru) the epidemiological situation has cultural development and large population deteriorated. In addition to financial and movements, has been contained. Foci of operational factors, other problems hinder active transmission are, however, spreading control, such as resistance of malaria malaria to receptive areas outside the vectors to the current insecticides, which epidemic area. A working group on are also widely used in agriculture, and receptivity to malaria and other parasitic resistance of P. falciparum to the 4-amino­ diseases was convened (Izmir, Turkey, quinolines. I978).1

9.26 In the South-East Asia Region 9.28 In the Eastern Mediterranean Re­ the reduction in the number of cases gion Cyprus, Israel, Lebanon and a few reported during the last two years seems other areas are free from malaria. The risk to indicate an overall improvement in the remains moderate to high in the remaining malaria situation. A significant reduction part of the Region. Fewer malaria cases in the incidence was reported in India, the have been reported for Afghanistan, Iraq, number of cases decreasing from 4·7 mil­ and Pakistan, but the incidence is on the lion in I977 to 3·7 million (provisional rise in Iran and the Syrian Arab Republic. data) in I978. In Sri Lanka the incidence A coordinated malaria programme in the decreased by about 70% in I 978 as com­ Arabian peninsula, to be carried out pared with I 977. A deterioration of the simultaneously in Democratic Yemen, epidemiological situation was reported for Oman, the United Arab Emirates, and Bangladesh and Burma : in the former the Yemen, is still in preparation. case detection system has not yet been reorganized to an adequate level, and in 1 World Health Organization. Receptivity to malaria the latter the programme is hampered by and other parasitic diseases. Report on a WHO working group. Copenhagen, 1979 (EURO Reports and Studies, serious administrative, operational and No. 15). THE WORK OF WHO, 1978-1979

9.29 In the Western Pacific Region and the Sudan will also be used for the Australia, Brunei, Hong Kong, Japan, training of Arabic-speaking staff. and Macao remain free of malaria and the risk is minimal in the Republic of Korea 9·31 Courses on the in vitro testing of and Singapore. Malaria is being contained P. falciparum susceptibility to the 4-amino­ in large areas of China. In peninsular quinolines were held in all the WHO Malaysia considerable progress continues regions except that of Europe. To enable to be made and about 70% of the popula­ national services to apply serological tech­ tion are now living in areas free from the niques for epidemiological evaluation, disease ; the prospects for malaria control workshops on the enzyme-linked immuno­ in Sarawak are good and in Sabah the sorbent assay were organized in Beijing situation now appears stabilized after a and Shanghai(China), Jena(GermanDemo­ deterioration that started in 1973. In the cratic Republic), Moscow, New Delhi, and Philippines, while 40% of the population Zagreb (Yugoslavia). Under the auspices live in areas where the malaria risk is of the Special Programme for Research negligible, an increase in the incidence has and Training in Tropical Diseases, courses been reported in the rest of the country on the in vitro cultivation of P. falciparum since the early 197os. For the Lao People's were held in Bangkok, Beijing, Belem Democratic Republic and Democratic Kam­ (Brazil), Ibadan (Nigeria), and Shanghai. puchea, unofficial reports suggest that the A review of research within the framework malaria situation is serious. In the Solomon of the Special Programme was carried out Islands the efforts made since 1977 have with the participation of malariologists, failed to prevent an epidemic situation. scientists, public health administrators, Similarly, in Papua New Guinea a 50% and representatives from tropical coun­ increase in cases was reported in 1977, tries and the WHO regions. Coordination 1978, and 1979. meetings were also held with international and bilateral agencies.

9· 30 One of the main priorities of the 9·32 In the field of chemotherapy, malaria action programme is the develop­ clinical trials with mefloquine were begun ment of the necessary human resources in Brazil and others approved for Thailand through the promotion and support of a and Zambia. Other fields given special training programme. WHO initiated emphasis were : the development of a action to establish a permanent interna­ microtechnique for testing P. jalciparum tional secretariat to be based in an Asian sensitivity to antimalaria drugs ; the formu­ country, to support the development of a lation of sustained release systems ; reduc­ regional comprehensive training pro­ tion of the toxic effects of primaquine by gramme for malarious countries of Asia. 1ysosomotropic techniques ; genetic studies Plans are being made to cooperate with on drug resistance ; the mode of action of Member States in the development of antimalaria drugs ; and the development similar programmes for Africa and the of methods for screening long-acting blood Americas. For countries of the Eastern and tissue schizontocides. Mediterranean Region, courses are organ­ ized for professional staff by the Ain Shams 9·33 In the field of immunology, efforts University, Cairo, and the School of were mainly directed towards the purifica­ Public Health, Teheran, but it is expected tion and fractionation of parasite antigens that training facilities existing in Baghdad as a prerequisite for the standardization of

104 COMMUNICABLE DISEASE PREVENTION AND CONTROL serodiagnostic techniques and the develop­ status and requirements of global malaria ment of malaria vaccines. Studies also control were considered. It subsequently continued with the aim of clarifying the continued discussions with bilateral phenomena involved in the immune re­ agencies, from which it transpired that sponse following natural infection. In view most potential donors would prefer a of the experience gained so far with coordinated consortium type of assistance. immunizing agents, the search was con­ This approach has been adopted in Nepal, tinued for adjuvants applicable to human Sri Lanka, Sudan, and Turkey. medicine. 9·37 Consultations continued with 9·34 Research on basic biology covered USAID on the development of the training areas essential to the implementation of programme for the Americas and Asia, strategic plans in chemotherapeutics and with the possibility of a similar programme immunology. These activities are con­ for Africa later. WHO participated in a cerned mainly with the mass production of workshop in Washington in connexion exoerythrocytic stages, parasitic isolation with the development of malaria control and fractionation, the mechanism of para­ programmes for Africa. site invasion of host cells, parasite meta­ bolism related to antigen production, drug action, and the development of new animal Other parasitic diseases models for drug and vaccine testing. 9.38 In both tropical and subtropical 9· 3 5 In applied field research global countries parasitic diseases remain serious collaborative studies were carried out on public health problems, with a depres­ the drug response of malaria parasites, singly high prevalence of the major proto­ and a project was continued in Bendel zoal and helminthic infections. Their State, Nigeria, that aims at selecting the impact on the economies of developing best methods for malaria control with the countries, too, is insufficiently appreciated. means currently available under different They have increasingly become recognized ecological conditions and at extrapolating as complex syndromes, often not amenable the results to other parts of Nigeria and to simple control measures because of tropical Africa. Other projects that started their intimate association with human in 1979 deal with: (1) species complexes behaviour and the human environment. of malaria vectors, their epidemiological Many have complicated transmission cycles importance, and their bionomics and eco­ and some have animal reservoirs of in­ logy in relation to amenability to control ; fection. Continuing efforts for their (z) spraying equipment, the formulation control and increased research are needed. of insecticides to be used against larval and adult stages of mosquitos, insecticide Schistosomiasis resistance, and the use of larvivorous fish ; (3) the use of antimalaria drugs; and (4) 9·39 Consultant teams in an inter­ the implementation of antimalaria oper­ regional project reported on health dangers ations with the active participation of the in African man-made lakes and in the community. major water resources development pro­ jects in South America and South-East 9.36 WHO convened a meeting of Asia, and comprehensive bibliographies donor countries in 1978 at which the of the risks associated with such projects THE WORK OF WHO, 1978--1979

were produced. The aim is to elaborate of the large national control programme and disseminate a methodology for the launched in 1976 revealed good progress. prevention of parasitic infections in water In Egypt, assistance was provided in resources development schemes and to redesigning the strategy of control in the draw the attention of potential funding light of the epidemiological circumstances. sources to the danger to health that they In the Philippines, a regional committee involve. was set up for research into S. japonicum infections and a compilation of inter­ 9.40 WHO was the executing agency nationally assisted land development pro­ for the originally UNDP-financed research jects was prepared ; the Government is to project on the epidemiology and method­ include schistosomiasis control as an in­ ology of control of schistosomiasis in trinsic component in all development man-made lakes. This project, through schemes in endemic areas. the application of an integrated control strategy combining the identification of 9·43 In the Eastern Mediterranean Re­ transmission sites with regular focal mol­ gion assistance was given in continued lusciciding, annual selective chemotherapy evaluation of the highly successful schisto­ for the infected population, continuous somiasis control programme in Tunisia. health education, and the installation of Teaching was undertaken at the second village water supplies, has made funda­ postgraduate course in Teheran ending mental advances in the control of schisto­ in 1978 for the master's degree in public somiasis in man-made lakes in Africa and health, the emphasis of the course being produced a highly satisfactory reduction on malaria and parasitic diseases. Recently in the prevalence, incidence, and intensity an ambitious project for a comprehensive of infection. In December 1978 the project approach to the prevention and control was formally transferred to the Govern­ of water-associated diseases in irrigation ment of Ghana. The continuation of systems was launched in the Sudan. The research has been secured by the support aim is to reduce malaria, schistosomiasis, of the Special Programme for Research and diarrhoeal diseases in the Gezira, and Training in Tropical Diseases. Managil, and Rahad irrigated areas by the use of multiple integrated control tech­ 9.41 There was close and continuing niques in which the emphasis is on environ­ collaboration between WHO and a pharma­ mental modification. Preliminary technical ceutical company in developing a new planning has been carried out and the schistosomicide, praziquantel, which is first meeting of the scientific advisory effective orally against all three main group held. species of schistosome infecting man and promises to be a fundamental step forward 9·44 In the African Region agreement in population-based chemotherapy of these was reached between the Federal Republic infections. The compound will be used of Germany and the Regional Office for in further jointly planned extensive field the provision of financial and technical 1 trials. cooperation in the Government of the Congo's schistosomiasis control project in 9.42 Technical cooperation continued the Niari valley in the area of Loubomo. with Member States. In Brazil, assessment WHO collaborated with the Government of the United Republic of Tanzania in finalizing 1 Bulletin of the World Health Organization, 57 (5): 767-771 (1979)· the strategy of schistosomiasis control that

106 COMMUNICABLE DISEASE PREVENTION AND CONTROL it hopes to implement in Zanzibar through 9.50 The problems of keeping the a primary health care approach. incidence rates of Bancroftian filariasis low in many South-East Asian countries 9·45 In the Special Programme for and Pacific islands through mass adminis­ Research and Training in Tropical Diseases tration of diethylcarbamazine were explored (paragraphs 9.213-9.239 below) research and maintenance strategies using primary activities continued through the mechanism health care approaches were developed. of the Programme's scientific working WHO support was given to national groups and steering committees. Numerous epidemiological surveillance and vector research projects in the immunology, control. A meeting of a research study chemotherapy, and epidemiology of schisto­ group on Bancroftian filariasis of the somiasis were financed. South-East Asia and Western Pacific Re­ gions (New Delhi, I979) reviewed the 9.46 Close cooperation was maintained epidemiological situation, identified re­ between WHO and the major national, search priorities and proposed ways of international, and private agencies con­ employing existing institutions or pro­ cerned with research on and the control grammes for the conduct of research. of schistosomiasis.

9· 5 I In Africa the problem of oncho­ 9·47 For other snail-borne trematode cerciasis and river blindness continues to infections, a task force met to identify predominate. Although the transmission research priorities and plan future control of onchocerciasis can be controlled by the activities (Manila, I 979). continuous use of larvicides against Simu­ lium, the treatment of infected persons at Filarial infections (including onchocerciasis) high risk of blindness remains extremely difficult. Chemotherapeutic trials were 9·48 WHO assisted Brazil in the plan­ organized in Ghana, Mali, Sudan, United ning and evaluation of the campaign to Republic of Tanzania, and Upper Volta. control Bancroftian filariasis by selective chemotherapy with diethylcarbamazine and 9· 52 Assistance was given to Liberia, in the planning of a strategy to contain Nigeria, and Sudan in the control of the threatened spread of onchocerciasis in onchocerciasis. In Sudan WHO helped the Amazon and Orinoco river basins. the Government to finalize a plan for Workshops on the taxonomy of simuliids onchocerciasis research and control to of medical importance were held in Brazil begin in I98o. Work in relation to the and Venezuela. A small simuliid control onchocerciasis control programme in the trial was begun in Guyana. Volta River basin continued (see para­ graphs 9.54-9.6I below). A global re­ 9·49 In China material assistance was search programme was begun, funded given to determine, by blood filtration mainly by the Special Programme for techniques, whether previously conducted Research and Training in Tropical Diseases. diethylcarbamazine campaigns have elimi­ In the search for new drugs effective nated Wuchereria bancrofti in some counties. against the adult filarial worm, particularly In Indonesia and Malaysia the outstanding Onchocerca volvulus, a network of labora­ problems of control of Brugian filariasis tories was supported in Australia, the were investigated, especially in those areas Federal Republic of Germany, Japan, the where there are animal reservoirs. United Kingdom, and the United States

I07 THE WORK OF WHO, 1978--1979 of America, where some z 5oo or more 9· 56 The vector continues to be con­ compounds can be screened for filaricidal trolled by the aerial application of insecti­ activity each year. cide, using up to eight helicopters and two fixed-wing aircraft. In 1979 a new aerial 9· 53 Studies are being conducted in spraying contract was signed for the Malaysia, Mali, Nigeria, Samoa, Sri Lanka, period I98o-1982. Sudan, United Republic of Tanzania, and Upper Volta in which drugs already ap­ 9· 57 Research financed by the pro­ proved for human _medicine are used in gramme was carried out under contract clinical trials against human filarial with institutions and by consultants. Con­ infection. siderable progress was made in under­ standing the reinvasion phenomenon and Onchocerciasis control programme in developing morphological characteristics to identify the different species of the 9·54 WHO's executive function in rela­ S. damnosum complex. Trials of new tion to the onchocerciasis control pro­ insecticides continued in an endeavour to gramme in the Volta River Basin area find an alternative to temephos. The (West Africa) continued during 1978-1979, aquatic monitoring programme was main­ which represented the last two years of the tained, and data collected indicated minimal first financial phase of that programme. effect on the riverine invertebrate fauna Consequent on a decision of the Joint and no change in river productivity. Coordinating Committee, operations were extended southwards in I vary Coast and the 9· 58 The socioeconomic development 2 programme area now covers 785 ooo km • of the area is the responsibility of each Concurrently, at the request of the govern­ participating government, and at the 1979 ments, studies on further extension were Joint Coordinating Committee meeting undertaken south of the area, in Benin, each country presented its own progress Ghana, and Togo. report. WHO is emphasizing the public health component of all development 9· 55 Encouraging results were record­ activities. In order to obtain a better ed, with the vector, Simulium damnosum, understanding of the socioeconomic effects being successfully controlled and trans­ and implications of onchocerciasis control, mission of the parasite, Onchocerca volvulus, and also develop national expertise for drastically curtailed. In approximately 8o% undertaking studies, a programme of of the original territory the annual biting training and research was introduced. rate of the vector was below 1000 at the end of 1979, and the annual transmission 9· 59 In preparation for the second potential below Ioo-levels corresponding financial phase, 1980-1985, an evaluation to the criteria adopted in 1977 for the report on the programme was prepared settlement of populations in the river in 1978, the first part dealing with oper­ valleys. The second round of epidemio­ ations and costs and the second with the logical surveys revealed that there was not socioeconomic implications. The World only a stabilization of the clinical situation, Bank convened two meetings of potential but also a recognizable decline in the donors (Paris, 1979) as a result of which number of new cases in the younger age financial support was pledged for the groups, as well as indications of reduced operations over the next six years, the intensity of infection. estimated cost being approximately

!08 COMMUNICABLE DISEASE PREVENTION AND CONTROL

US $Io6 million. New donors were 9.63 Several governments, notably Switzerland and the OPEC Special Fund ; members of the Organization for Co­ in addition, the participating governments ordination in the Control of Endemic agreed to increase significantly their mone­ Diseases in Central Africa, have again tary contribution to the programme. accorded high priority to trypanosomiasis control ; the Congo Government has estab­ 9.6o New structures were approved for lished a national programme that includes the second phase. The Joint Coordinating intercountry efforts for the control of Committee will be replaced by a Joint endemic areas on its borders with Gabon Programme Committee, again composed and Zaire. WHO provided technical and of members from donor and participating material assistance to Mozambique and countries and from sponsoring agencies. Uganda to alleviate immediate control The Scientific and Technical Advisory needs. Committee, the Ecological Panel, and the Economic Development Advisory Panel, 9.64 During the period under review which have advised regularly on relevant three new serodiagnostic tests emerged aspects of the programme, will be replaced from laboratory research supported by by a I z-member Expert Advisory Com­ WHO ; they can provide results on the mittee. The latter will make a single spot within one hour after blood sampling. report to the Joint Programme Committee, Trials under field conditions are taking reviewing the operational, research, en­ place in Ivory Coast, United Republic of vironmental, and economic development Cameroon, and Zaire. activities of the programme. 9.6I The Director-General of WHO 9.6 5 Simple means of vector control in I 978 established an independent com­ are being introduced. Traps and screens mission to advise on the long-term pros­ impregnated with insecticides are being pects of the programme. Under its terms tried out in West Africa as a means of of reference, this commission will be reducing the contact between man and concerned with alternative appropriate tech­ Glossina, although it is not anticipated that nologies for control, the possible role of they will control the tsetse population chemotherapy, the effects on present activi­ completely. A third phase of large-scale ties of extending the area of control, and insecticide spraying by helicopter was the feasibility of controlling other vector­ completed ; this is an effective and eco­ borne diseases under the programme. logically justifiable technique for spraying It will also determine the structures, riverine vegetation in the moist savanna. national and international, that are required It is a relatively costly technique, for use to ensure effective maintenance of the only in emergencies when rapid interrup­ programme's achievements beyond I985. tion of the transmission cycle is required. 9.66 The extensive WHO-executed African trypanosomiasis applied research programme in West Africa 9.6z In the last two years the reported initiated with UNDP funds was transferred incidence of sleeping sickness has shown in I978 to the Special Programme for a steady increase. Several epidemic resurg­ Research and Training in Tropical Dis­ ences were also reported in Uganda and eases, with additional funding support the United Republic of Cameroon, while from voluntary contributions (paragraph the foci in Sudan are still active. 9.226 below). Training within this pro- THE WORK OF WHO, 1978-1979 gramme has become increasingly important lishment of two associated reference serum and WHO has cooperated with FAO and banks, one in Argentina and one in Brazil. the OAU International Council for Try­ 9.70 A workshop was held in Brasilia panosorruasls Research and Control. in I979 under the aegis of the Special Following a joint OAU/FAO/WHO semi­ Programme for Research and Training in nar in Nairobi, a course on surveillance Tropical Diseases to standardize methods organized in Zaire was sponsored by the of epidemiological surveillance and clinical Special Programme, and in I 979 a course examination. on tsetse ecology and control was held in Bobo-Dioulasso (Upper Volta). In addition some zo individual research grants were Leishmaniases made through the research-strengthening 9·7I Recent outbreaks of kala-azar in group of the Special Programme to visiting India and Kenya reemphasize the import­ research workers and trainees from endemic ance of the leishmaniases. In most coun­ countries. tries of the Eastern Mediterranean Region 9.67 Thirty research projects are being the infantile form of visceral leishmaniasis supported by the Special Programme as has again become a high-priority health problem, notably in Afghanistan, Iran, well as I z under the WHO regular budget. Research, control, and training are carried and Iraq. out in close collaboration with OA U and 9.7z A workshop was organized in F AO, the three organizations being repre­ Brasilia for the standardization of clinical sented in all the technical committees, trials and the treatment of mucocutaneous including expert committees and the Special leishmaniasis in South America. In col­ Programme's scientific working groups laboration with the Gorgas Memorial and steering committees. Laboratory, Panama, PAHOjWHO began a programme in I978 to produce and American trypanosomiasis distribute antigens and reagents to national laboratories and give technical training to 9.68 The Chagas' disease programme health workers in affected countries. carried out jointly with PAHO has been principally oriented towards coordinated Gastrointestinal protozoal and helminthic data collection and standardization of infections research and control techniques. Through P AHO an exchange of health personnel 9·73 The international register of hel­ involved in Chagas' disease control took minth species and strains, which is of great place between Bolivia, Ecuador, Paraguay, value to parasitologists in the maintenance and Peru. An attempt at control of Chagas' of helminth cycles, was brought up to disease by improving traditional rural date. Consultant advice on chemotherapy housing was made in Brazil with emphasis and epidemiology was given to Member on sanitary education, and in Venezuela States requesting it and in relation to the through the Chagas' disease research centre Cape Verde helminthiasis control project. in Maracay, operated collaboratively by Assistance was given to the Rockefeller WHO/PAHO and the Government. Foundation in the development of a pro­ gramme strategy for research into hel­ 9.69 In serodiagnostic standardization minthic infections of the gastrointestinal a significant step was taken with the estab- tract.

IIO COMMUNICABLE DISEASE PREVENTION AND CONTROL

Bacterial and viral diseases regional level in Tokyo. Regional training was provided at Buenos Aires and Caracas. Tuberculosis and other communicable diseases In Washington, DC, at the third regional affecting the respiratory .rystem seminar on tuberculosis of the American Region, recent advances in the chemo­ 9·74 About 3·5 million people develop therapy of tuberculosis and their practi­ tuberculosis each year ; more than half a cability in national programmes were million die from it ; and the estimated discussed. The present situation of tuber­ annual incidence of the pulmonary form culosis control in the Caribbean was in some areas is as high as 30o-5oo cases analysed at an intercountry seminar held per Ioo ooo inhabitants. Although the in Trinidad and Tobago. National seminars risk of infection is generally on the decline, and conferences on tuberculosis control in some developing countries the decline, were supported in Bolivia, Brazil, Colom­ if any, is relatively slow. bia, India, Mexico, and Nepal. Several of these meetings were held in close collabo­ 9·75 For operational and economic ration with the International Union against reasons tuberculosis control must form part Tuberculosis. of primary health care. A control techno­ logy appropriate for this approach is now 9· 77 A textbook on tuberculosis case­ available, and WHO collaborated in the finding and chemotherapy, in the form of planning and implementation of integrated questions and answers, was published 2 national tuberculosis control programmes as a commentary to the ninth report of (e.g., in Nepal, the Philippines, and the the WHO Expert Committee on Tuber­ United Republic of Tanzania) and in pro­ culosis.3 It will be available in English gramme evaluation (e.g., in Argentina, and French and is being translated into Cook Islands, Guam, Kiribati, 1 Mexico, Chinese, Japanese and Spanish. A manual New Hebrides, Republic of Korea, Singa­ on norms and procedures for integrated pore, Solomon Islands, Trust Territory of tuberculosis programmes in Latin American the Pacific Islands, Tonga, Tuvalu, and countries was published in Spanish by Venezuela). Technical collaboration also PAH0.4 The International Union against continued with Afghanistan, Bangladesh, Tuberculosis technical guide to sputum Brazil, Burma, Democratic Yemen, Paki­ examination for tuberculosis by direct stan, Papua New Guinea, Somalia, and microscopy as well as a PAHO/WHO Yemen. In the United Republic of Tanzania teaching aid on the same subject have been tuberculosis and leprosy control is provided given worldwide distribution through the jointly in one programme. The Regional regional offices. Office for Africa invited representatives from I 5 African countries to a consultation 9.78 In spite of the comprehensive on integration, with emphasis on leprosy research programme that has been carried and tuberculosis services, in Monrovia out in the field of tuberculosis and its in November I979· 2 Toman, K. Tuberculosis case-finding and chemotherapy: questions and answers. Geneva, World Health Organiza­ 9· 76 The training of national key wor­ tion, 1979. kers in the epidemiology and control of 3 WHO Technical Report Series, No. 5 p, 1974. tuberculosis was organized at the inter- 4 Pan American Health Organization. Control de tuberculosis en America Latina. Manual de normas y procedimientos para programas integrados. Washington, 1 Formerly Gilbert Islands. 1979 (Publicaci6n Cientifica, No. 376).

III THE WORK OF WHO, 1978-1979 control, there obviously are still sub­ plays in the development of infection as stantial lacunae in our present knowledge. compared with endogenous reactivation of This was clearly borne out by the sur­ a former infection. prising, and so far not well understood, 9.8o Because of the high prevalence of findings of the tuberculosis prevention mycobacteria other than Mycobacterium trial in India in which WHO, with financial tuberculosis in tropical and subtropical coun­ assistance by DANIDA, collaborated with tries, tuberculin testing as a means of the Indian Council of Medical Research. measuring infection rates lacks the usual The project presented the findings of the precision in those countries where, in the first 77'2 years of follow-up. 1 The incidence absence of reliable statistics, this surveil­ of infection was high in the study popula­ lance technique is most needed. In addi­ tion ; the incidence of bacillary disease was tion to continued efforts to isolate a more higher among initial tuberculin reactors species-specific tuberculin preparation, it (especially among older persons) than has been suggested that comparison of the among non-reactors (of which the majority tuberculin reactions before and after BCG were in the younger age groups) ; and the vaccination of the entire survey popula­ distribution of new cases of bacillary tion might provide a clearer separation of tuberculosis among those not infected at infected from non-infected individuals. intake did not show any evidence of a This new approach is now being sub­ protective effect of BCG vaccine. Great mitted to field testing. caution is needed in extrapolating the findings to other areas, even in India, and 9.81 The effectiveness and cost-benefit since infant tuberculosis was not observed of different programme approaches to in the trial the present results cannot be tuberculosis control in the community extrapolated to infants. Although pros­ were studied in Romania with WHO pective as well as retrospective studies support, while in Algeria case-finding and appear to confirm that BCG provides a diagnostic techniques in rural areas were high level of protection from all forms of the subject of evaluation and the applica­ childhood tuberculosis, recent informa­ bility of short-course chemotherapy is tion on its effect in infancy is scarce and being studied in terms of overall pro­ more research is needed, especially now gramme effectiveness (cure rates). Similar that BCG vaccination has become a com­ studies were supported in Chile, Colom­ ponent of the Expanded Programme on bia, and Japan. Immunization. In this connexion, WHO continued to collaborate with Hong Kong 9.82 It is estimated that about 2.2 mil­ and with the Medical Research Council, lion deaths occur every year in the world London, in a BCG vaccination trial in from acute respiratory infections, mostly pneumonias. If all the reported causes of newborn infants. death are taken into account, pneumonia 9·79 Research on mycobacteriophages contributes about 5 %, although there are received support, since it may throw new considerable differences between and within light on the geographical distribution of continents, the percentages ranging between tubercle bacilli of different levels of viru­ 13.6 and 3. 3. For the child population lence and on the role exogenous reinfection alone respiratory infections may account for up to 26% of the mortality.1 The main

1 Bulletin of the World Health Organization, 57 (5): 1 Bulletin of the World Health Organization, 56 (3) : 819-827 (1979)· 481-498 (1978).

Il2 COMMUNICABLE DISEASE PREVENTION AND CONTROL task in this new programme area, which Pacific Region, with collaboration from started in I978, is to develop a simplified the Australian Government. A task force technology for the clinical management and proposed details for a regional programme prevention of such infections, and to find (focusing to start with on Fiji, Papua New ways of applying it as a component of Guinea, and the Philippines), and a regional primary health care. 1 advisory panel was created for periodic technical review of the programme and 9.83 Technical and financial support monitoring of its implementation. Direct was given to studies of the type, relative involvement of, and support by, the frequency, and distribution of acute res­ scientific community and national health piratory diseases as well as to the develop­ authorities were among the aims. A ment of simple (and standardized) decision research centre was established at Goroka trees for diagnosis and treatment. A (Papua New Guinea) to conduct clinical, general design was formulated for a immunological, epidemiological, and demo­ development strategy for programmes that graphic investigations as well as to provide would allow countries themselves to devise research and management training facilities. management schemes appropriate to the The problems of acute respiratory infections existing health infrastructure and so oper­ and of programme development were the able by maternal and child health services subject of the Technical Discussions at the and by the general health services as part Regional Committee in I 979· of primary health care at village level. Programme development along these lines 9.86 WHO maintained close collabo­ was begun in the United Republic of ration with the International Union against Tanzania, with the support of the Govern­ Tuberculosis through its scientific com­ ment of the Federal Republic of Germany. mittee on respiratory diseases. It also collaborated with the Communicable Dis­ 9.84 A WHO scientific group on acute ease Center, Atlanta, USA, in respect of viral respiratory diseases met in I 979· 2 legionnaires' disease. One of its recommendations was that the activities of national influenza centres should be extended to include other respiratory diseases. The way such centres Leprosy would monitor the clinical management of acute respiratory cases in the community 9.87 The Thirty-second World Health was the subject of a separate meeting. Assembly (resolution WHA32·39) called on By the end of I 979 a programme on the Member States to allocate adequate re­ application of virus and bacterial diagnosis sources for carrying out effective leprosy to the evaluation and management schemes control programmes, and on WHO to of acute respiratory disease in primary develop further the research aspects of the health care was launched. Special Programme for Research and Train­ ing in Tropical Diseases. WHO is con­ 9.85 Development of the new pro­ centrating on (a) the cooperative develop­ gramme on respiratory infections was ment of effective leprosy programmes energetically pursued by the Western within national health programmes, (b) the training of adequate multidisciplinary per­ 1 WHO Chronicle, 32: 286-290 (1978). sonnel, and (c) increased research efforts 2 WHO Technical Report Series, No. 642, 1980. under the Special Programme.

II3 THE WORK OF WHO, 1978--1979

9.88 Collaborative research other than gramme managers, and this will appear under the Special Programme is progres­ as a nonserial publication in I 980. sively developing into operational and epidemiological research and into tech­ 9.9z A standard recording and report­ nical cooperation, such as supplying lepro­ ing system was devised as a research pro­ min to leprosy control programmes and ject in collaboration with the Epidemio­ materials for sulfonuria field testing. logy Unit, Louvain University, Brussels. It is at present undergoing field testing 9.89 According to the latest data there in I I countries. If found acceptable, this are probably not less than 4 million regis­ system could be in general use by I981. tered leprosy patients in the world and the estimated number of cases is IO 500 ooo. 1 9·9~ In Africa, consultants reviewed The only method of control available at leprosy control programmes in nine coun­ present is secondary prevention by chemo­ tries. In I978 and I979, z~ nationals from therapy for known cases and surveillance I7 countries participated in courses on of contacts. The effectiveness of chemo­ leprosy at the Dakar Institute of Applied therapy in infectious cases has, however, Leprology and at the All Africa Leprosy been partly undermined by the emergence and Rehabilitation Training Centre in of sulfone resistance, the incidence of Ethiopia. A consultation on integration, which probably varies in its seriousness in with emphasis on leprosy and tuberculosis different parts of the world. Research is services, was convened by the Regional vital to solve the technical and operational Office and cosponsored by the Inter­ problems posed by the present limited national Union against Tuberculosis (Mon­ strategy of secondary prevention, parti­ rovia, November I979)· There were cularly research to develop a vaccine for I 8 participants from nine countries. The primary prevention and also potent thera­ meeting provided a useful exchange of peutic regimens based on a combination ideas on how to integrate specialized of drugs. leprosy and tuberculosis activities into the general health services, including primary 9.90 Regional leprosy advisory com­ health care. The purpose of these courses mittees or working groups were estab­ and meetings was to train teachers for the lished in the South-East Asia and Western integration of leprosy control into primary Pacific Regions for the purpose of selecting health care. areas for coordinated action that would be of benefit to the countries in those regions. 9·94 In the Americas a standing com­ Coordination meetings with voluntary mittee on leprosy control, coordinated by agencies and associate members of the the Caribbean Epidemiology Centre, aims International Federation of Antileprosy at making the best use of the resources Associations strengthened cooperation with available in the area. Similar committees governments in leprosy control services. were established in Central America and are being planned for other countries. 9·9I WHO revised and issued a guide to leprosy control in the form of a document 9·95 In South-East Asia an alternative particularly addressed to planners and pro- approach to the treatment of multibacillary forms of leprosy was studied in the rifam­ picin trial in Burma. The first phase, in 1 Week& Epidemiological Record, 3: q-23 (1979). which lepromatous patients who have

I I4 COMMUNICABLE DISEASE PREVENTION AND CONTROL become noninfective by rifampicin treat­ gency cases, which started in I977, is being ment are identified, was completed. carried out with the participation of six laboratories in different parts of the world. 9.96 A workshop on community in­ volvement and participation in leprosy 9· IOI Streptococcal infections. Vaccines control, jointly sponsored by the Govern­ against Streptococcus pneumoniae infections ment of Nepal, WHO, and the Sasakawa are available, but their serotype content Memorial Health Foundation, took place is based on prevalence studies in only a in Kathmandu (October I979). There were few countries, the distribution of sera­ 30 participants and observers from 22 coun­ types not yet having been established for tries. The workshop provided much most countries. In I979 WHO initiated an useful information on the role the com­ international cooperative study on the munity should play in leprosy control. typing of S. pneumoniae. WHO collabo­ rating centres were established at the 9·97 In the Western Pacific Region State Serum Institute, Copenhagen, and WHO sponsored a sociological study in at the University of Pennsylvania (United Papua New Guinea on community be­ States of America). Twelve laboratories in haviour with regard to leprosy. A second different countries were designated for training course on leprosy took place in participation in the study in I979· Suva (April I 979), with 2 I participants from seven countries. Also in Fiji, a 9.Io2 WHO continued to coordinate national seminar on leprosy control and the work carried out by the WHO col­ management of leprosy patients was spon­ laborating centre in Prague for reference sored by WHO, at which there were and research on streptococci, with the I 3 participants. participation of laboratories in different parts of the world. 9.98 For research in leprosy by the Special Programme for Research and 9· I03 Cerebrospinal meningitis. Several Training in Tropical Diseases, see para­ serious epidemic outbreaks affected numer­ graph 9.229 below. ous countries in I978-I979, particularly in Africa. WHO provided these countries Other acute bacterial diseases with technical and material assistance. Applied research was started by WHO 9·99 Diphtheria, pertussis, tetantts. Tech­ with a view to putting simplified methods nical cooperation with countries and col­ of diagnosis at the disposal of health laborative research on specific problems services that would permit rapid and early in relation to the Expanded Programme identification of meningitis. This should on Immunization continued in I979, with lead to specific prevention and immu­ the aim of improving the efficacy of nization. existing vaccines and developing new ones. Of particular importance was a coordinated 9.I04 A workshop on these problems research project to develop a protective was held in Africa in I978, and an inter­ fraction of pertussis antigen with low toxic national conference sponsored by WHO properties. in I979 studied the problem of developing effective vaccines for those meningococcal 9· Ioo An international cooperative serogroups against which existing vaccines study on the immunological effectiveness are still powerless, as well as for other and safety of tetanus prophylaxis in emer- pathogenic agents such as Haemophilus

II5 THE WORK OF WHO, 1978-1979 inftuenzae and S. pneumoniae that are res­ infertility-was carried out in several re­ ponsible for meningitis, particularly in gions, encouraged and financed in part children. by WHO. Operational research based on a simplified methodology within the pri­ 9.Io5 Plague. An informal consultation mary health care framework was also on plague surveillance and control was carried out, particularly in Africa. The held in Geneva in I979· The meeting first results were highly encouraging and emphasized the need (a) to increase the there is ground for hope that effective manpower in developing countries by standardized control can be developed. providing training for plague workers at This new approach was supplemented by all levels, (b) to establish fully equipped research on the feasibility of a social and fully staffed regional laboratories, approach to control in rural areas and on and (c) to strengthen the laboratory and the reliability and sensitivity of simplified epidemiological capabilities in countries diagnostic methods accessible to even the where a specific endemic or epidemic least sophisticated laboratory. situation is causing serious problems. In I979 preliminary steps were taken to 9· I09 Effective treatment remains the establish regional collaborating centres in basis of successful control. Worldwide Africa and the Western Pacific and to surveillance of the sensitivity of the patho­ organize interregional and regional training genic agents to antibiotics was stepped courses. up with a view to helping health authori­ ties choose effective standardized methods 9.Io6 Cholera. Consultant services, of treatment. supplies, and equipment were provided for countries experiencing epidemics of cholera. 9.IIO Endemic treponematoses. The Eight new countries were infected with Thirty-first World Health Assembly drew cholera during I978 and two more in I979, attention to the resurgence of endemic but the total number of cases in the world treponematoses, in particular yaws and to remained much the same. their seriousness especially in children, of whom 10% are affected in certain 9.Io7 Sexuai!Jtransmitteddiseases. WHO, countries. An expanded intercountry in collaboration with nongovernmental and control programme for the populations national organizations, continued to pro­ at risk in affected areas, particularly in mote awareness of the importance of these Mrica, began in I979 with a cooperative diseases and their complications and of the study by interested countries to determine need for appropriate control measures. the extent of the problem and develop an Besides disseminating information on the appropriate methodology to interrupt trans­ present state of knowledge, it organized mission on the basis of the experience training courses at regional and national gained in previous mass treatment cam­ level to train the participants to apply effec­ paigns. Thus programmes could be tive standardized control methods, not only integrated into other public health pro­ medical but also socioeconomic, integrated grammes aimed at the same target popula­ into all levels of the public health structure. tions, as part, for example, of the Expanded Programme on Immunization. 9.Io8 Research on the most serious individual and socioeconomic consequence 9· I I I For sexually transmitted viral of sexually transmitted diseases-acute pel­ and chlamydia/ diseases, see paragraphs 9.I23 vic complications, one of the main causes of and 9.I24 below.

n6 COMMUNICABLE DISEASE PREVENTION AND CONTROL

Viral, chlanrydial, rickettsial, mzd related disease than usual in older age groups, diseases and some fatal cases were reported.

9· I I 2 In spite of the increased availa­ 9. II 4 The reappearance of the HI N I bility of new and improved vaccines and antigenic subtype of influenza A virus of fresh possibilities for prevention and stimulated further research on the virus. treatment, viral diseases continue to cause This in turn led to a better understanding premature death, disability, and economic of the differences among the influenza A loss all over the world. Rapidly changing viruses. Use was made of this knowledge living conditions, urbanization, variations in revising the nomenclature of influenza A. in immunity, shifts and drifts of the anti­ A joint meeting of WHO and the Com­ genic composition of viruses, the appear­ municable Disease Center, Atlanta, USA, ance of a new virus strain or the implanta­ was held in I 978 proposed a system grouping tion of a known strain in a new milieu are of the viruses, whether human or animal, factors that give rise to new disease pat­ into I I groups ; this was published in the terns and epidemics. Bulletin of the World Health Organization. 1

9· I I; Influenza. Influenza A strain of 9· I I 5 Viral respiratory diseases other than the HINI subtype reappeared in I977 influenza. A WHO scientific group on acute after having been virtually absent for over viral respiratory diseases met in I 979 and 20 years. It spread all over the world, is described in paragraph 9.84 above. causing in general mild illness in the age 9· II 6 Viral hepatitis. Recent progress groups below 25 years. During I978 a in laboratory diagnosis has provided a minor antigenic drift was observed and better understanding of the epidemiology the new variant, AjBrazil/11/78 (HINI), of hepatitis and opened up the possibility had to be considered for inclusion in the of vaccination against hepatitis B and pos­ vaccines. An unusual feature of the I977/78 sibly hepatitis A. Other hepatitis viruses season was the concomitant circulation of have recently been identified. HINI and H;N2 subtypes of influenza A in many countries, occasionally even in 9·II7 A WHO collaborative serological one and the same local outbreak. The H;N2 study demonstrated the high prevalence of subtypes, A/Texas/I/77 and A/Victoria/ hepatitis B in the developing world and 3/75, were found in all age groups and the great variations among communities. were associated with more severe disease The same sera are at present being tested and excess mortality than the HINI for hepatitis A. subtypes. During the influenza season I978/79 a similar pattern evolved, with 9· I I 8 A network of WHO-recognized influenza A (HINI) predominating, al­ national centres for viral hepatitis was though in many instances H3N2 strains set up. were also found. During I979 the A/Brazil/ II/78 virus also spread to Australia, China, 9.II9 The Regional Office for the and the USSR. HINI strains that seemed Eastern Mediterranean sponsored two to differ from both the AjUSSR/9o/77 workshops on hepatitis, that in I979 and the A/Braziljii/78 were isolated. At introducing rapid diagnostic techniques the end of the season increased activity of influenza B was noted. This virus was 1 Bulletin of the World Health Organization, 57 (2) : frequently associated with more severe 227-233 (1979). THE WORK OF WHO, 1978-1979

to the participants ; to secure the necessary 9· r 24 Collaborative studies on cyto­ reagents the participants were trained to megalovirus have shown that half to prepare them. The Regional Office for two-thirds of the adult female population South-East Asia is sponsoring a collabo­ of developed countries have been exposed rative study (with Burma) on the vertical to this virus. In other areas the rate may transmission of hepatitis. An informal approach roo%, and in them the infection consultation was held in Geneva in 1979 rate in infancy varies from over 40% to to discuss progress in the field of hepatitis 70 %, to reach in some areas 9 5 %. A and evaluate its application to control further collaborative study on fetal infec­ measures. tion has shown that the presence of maternal antibody to cytomegalovirus does 9· r 20 Poliomyelitis. A programme of not protect the fetus from infection. laboratory support for the surveillance of poliomyelitis was started in 1978. A guide 9· r 2 5 Yellow fever. Outbreaks of yellow to poliovirus isolation and serological fever (mainly jungle yellow fever) were techniques was produced in 1979.1 reported from both the African and American continents during 1978 and 1979· 9· I 2 I The rapid progress in molecular In the American continent, increasing chemistry has opened the way to relatively infestation in urban areas by the vector, simple but efficient methods for the intra­ Aedes aeJ!)Ipti, increases the risk of the typic differentiation of wild and vaccine reappearance of urban yellow fever. The strains of the polioviruses and such methods strengthening of programmes by rein­ promise to provide accurate means of forced vaccination and vector control and investigating individual cases and out­ the improving of surveillance measures breaks. A WHO collaborative study of are priorities in both regions. these techniques was begun in 1979· 9· r 26 Dengue and dengue haemorrhagic fever. Dengue viral infections now consti­ 9·122 Diarrhoeal diseases. Two collabo- tute major public health problems in rative studies on the determination of the South-East Asia, the Western Pacific, and tole of viruses in the etiology of diarrhoeal tropical America. Dengue virus type r, diseases were carried on during the period, which was not found in the American in collaboration with laboratories in 14 countries. The preliminary results are now Region until 1977, spread during 1978 and 1979 from the Caribbean area to being evaluated. (See also paragraphs 9· I4o- Central America and Mexico. Dengue 9·I44 below.) virus type 4 was for the first time found in the Western Pacific Region in 1978, 9· I 2 3 S exuai!J transmitted viral and chla­ associated with outbreaks in China, and mydia/ diseases. A collaborative study on in 1979 appeared in French Polynesia. sexually transmitted chlamydia! infection was begun in 1979. The first phase will 9.127 The three regions mainly con­ elucidate the public health importance of cerned and the Eastern Mediterranean these infections in the developing world. Region were represented on a technical advisory committee that met in Manila 1 Di:imi:ik, I. & Magrath, D. I. Guide to poliovirus in I 978 and revised the technical guide isolation and serological techniques for poliomyelitis-surveillance. Geneva, World Health Organization, 1979 (WHO for the diagnosis and treatment of dengue Offset Publication, No. 46). haemorrhagic fever. The WHO collabo-

II8 COMMUNICABLE DISEASE PREVENTION AND CONTROL rating centre for research on its immuno­ laboratories in South and Central America. pathology continued its investigations on To increase the availability of reagents the immunological mechanisms and on for diagnosis and control, a fourth WHO the development of a vaccine. A research collaborating centre for rickettsial reference study group (New Delhi, I978 and I979) and research was established in I 979 in evaluated the prospects for a vaccine and the Center for Disease Control, Atlanta prepared a protocol for a centre and for (United States of America). multidisciplinary studies on the epidemio­ logy of dengue haemorrhagic fever. 9· I 32 Diseases restricted to circumscribed geographical areas. Some viral infections 9· I 28 Japanese encephalitis. This disease, may lead to severe haemorrhagic fevers which has been known in the Western with high mortality rates. Because of a Pacific Region for many years, caused specific animal reservoir the diseases have concern for the first time in the South­ a limited geographical spread. In some, East Asia Region, extensive outbreaks however, man-to-man transm1ss10n in­ occurring in India and Nepal during the creases the possibility of spread outside second half of I978. The disease later their natural geographical limits. Two spread to Burma, Thailand, and Viet Nam. such outbreaks of haemorrhagic fever with high fatality rates occurred in Iraq and in 9.I29 During the outbreaks in India Sudan, and in I979 WHO was requested the Regional Office was involved in to coordinate the containment operations building up national facilities for the pro­ and the epidemiological investigations. duction and quality control of vaccine. An interregional meeting in I979 reviewed 9· I 3 3 The outbreak in Sudan, which the situation, which differed somewhat occurred in the same areas as the Ebola from the classical picture in the Western virus outbreak in I 976, again proved to be Pacific Region, the much lower incidence associated with this virus. Experience had rate making systematic vaccination of the shown the vital importance of strict iso­ population unrealistic. Guidelines for the lation of the cases and the use of protective development of national control pro­ clothing and barrier nursing to prevent grammes and a technical guide on Japanese nosocomial spread, which in I976 had encephalitis were prepared at the meeting. been the main cause for the severity of the outbreak. After intensive case-finding 9· I 30 Rift Valley fever. Until recently and careful history-taking, 3 3 cases were endemic in Africa south of Sahara, it ascribed to the outbreak, of which 22 were spread in early I977 to the southern part fatal. In Iraq, seven cases of haemorrhagic of Egypt, and caused severe outbreaks fever occurred during October I979, of among human and animal populations of which five were fatal. Only the first the north-eastern parts of the Nile delta in three reported cases were related. Congo I977 and again in I978. The Regional virus was isolated from one of the cases. Office played an important role in contain­ ment operations and epidemiological 9· I 34 Two WHO consultations about investigation of the outbreaks. emergencies of this type took place in Moscow in I979· The aim of one was to 9· I 3 I Rickettsial diseases. Reagents were prepare a manual of clinical and laboratory distributed and laboratory proficiency test­ diagnosis and public health measures; ing programmes conducted in national of the other to produce a simple guide for

II9 THE WORK OF WHO, 1978-1979 the investigation and control of epidemics, 9· I 39 In I979, an expanded and revised meant to give developing countries self­ world list of virus laboratories was distrib­ reliance in outbreaks of communicable uted to the 6oo or more laboratories disease. providing information for the list, and to others on request. 9·I35 Rapid laboratory techniques. WHO has played a leading role in the develop­ ment of rapid, simplified, and accurate Diarrhoeal diseases laboratory diagnostic methods that do not require sophisticated laboratory equipment 9·I4o High priority was accorded by the Thirty-first World Health Assembly or highly specialized technicians. 1 It has promoted collaborative studies for the (resolution WHA3 1.44) to the development of an expanded programme for control of preparation of reagents, evaluation of the the acute diarrhoeal diseases, which con­ techniques, and training courses in their stitute a major public health problem in use, in cooperation with the European children of the developing world. A global and Pan American groups for rapid labo­ technical advisory group was established ratory viral diagnosis. Studies for the and met in May I978. 2 Following a review standardization and quality control of the of the extent of the problem and of recent reagents used were started. advances in knowledge, it helped formulate 9·I36 Two workshops on selected tech­ strategies for immediate implementation niques were organized, one in Stockholm and identify areas for further research. and the other in Cairo. Regional meetings and consultations took place in the six regions, to begin the 9·I37 Reagents programme. Reagents formulation of national and regional pro­ produced by the WHO collaborating grammes. centres were supplied to laboratories in 9·I4I In I978 and I979 about 55 coun­ 37 countries. In a special project a stock tries prepared plans for national pro­ of basic good-quality antigens for the ?rammes an~ some 20 others expressed most common acute and other viral dis­ interest. Whlle oral rehydration supported eases was distributed to 2 I laboratories by dietetic management is the basis of ~ainly ~ the developing countries, fo; treatment, WHO also promoted action on ~agnostic and epidemiological investiga­ other critical aspects of child care; environ­ t10ns or for the calibration of locally mental health measures for prevention of produced reagents. the diseases; and surveillance to evaluate 9·I38 Exchange of information. During programmes and help in the early detection I978 and I979 the network of participating and control of epidemics. Technical and laboratories in the WHO virus reporting managerial training materials were devel­ oped to assist in the training of national ~ystem was expanded, resulting in a 50% health workers.3 ~ncrease of data received in the system 1n I978 as compared with I977· Increased 9·I42 . At the UNICEF/WHO Joint participation of laboratories in the devel­ Committee on Health Policy Qanuary I979) oping countries was encouraged. UNICEF pledged full support for national programmes at the country level as an 1 • A~eida, J. D. et al. Manual for rapid laboratory viral 2 dzagnons. Geneva, World Health Organization (WHO WHO Chronicle, 32: 369-372 (19?8). Offset Publication No. 47). 3 Week(y Epidemiological Record, 16: 121-123 (1979).

I20 COMMUNICABLE DISEASE PREVENTION AND CONTROL integral component of primary health care. promote eye health. It is estimated 3 UNICEF collaborated with the programme that there are 28 million blind in the by providing oral rehydration salts and world, of whom 2 I million are now in supporting local production.1 developing, 5. 5 million in intermediate, and I .6 million in developed countries. 9· I43 Research was supported by UNDP and the World Bank, and global 9.146 A I2-member global programme scientific working groups were set up to advisory group was established in I978 review knowledge and set research pri­ and met again in I979· Four task force orities in relation to immunology and meetings were convened during this period vaccine development,2 epidemiology, clini­ -on strategic planning, on data on blind­ cal management, child care, and environ­ ness, on the training of auxiliary personnel mental health. Regional study groups in eye care, and on methods of assessment were established in five of the six regions of avoidable blindness. Regional meetings to identify regional research priorities and were held in the Regional Offices for the research workers and institutions. The Americas, South-East Asia, the Eastern number of WHO collaborating centres Mediterranean, and the Western Pacific, for diarrhoeal disease research was in­ to outline regional strategies and promote creased. A management scheme for the the formulation of national programmes. execution of the research programme was 9· I4 7 A network of WHO collaborating also developed. (See also paragraph 9· 122 centres for the prevention of blindness is above.) being established in all regions. In two of these-Baltimore (United States of America) 9· I44 WHO continued its collaboration and London-new centres or departments with the International Centre for Diarrhoeal were established within existing academic Disease Research, Bangladesh (formerly the institutions and will offer formal multi­ Cholera Research Laboratory, Dacca). disciplinary training in epidemiological and preventive ophthalmology. Prevention of blindness 9· I48 Close collaboration and coordi­ nation with nongovernmental organiza­ 9·I45 The WHO programme for the tions active in this or in related fields were prevention of blindness, established on developed, notably with the International I January I978, is a development of Agency for the Prevention of Blindness, earlier WHO activities. It was recognized the International Federation of Ophthalmo­ as a priority programme for technical logical Societies, the International Organi­ cooperation and its main emphasis is on zation against Trachoma, the International the promotion of national programmes. Union of Nutritional Sciences, and the Its long-term objectives are (I) to reduce World Council for the Welfare of the national blindness rates to less than 0.5 %, Blind. The first of these organizations has with no more than I .o% in individual established or recognized 56 national com­ communities, and (2) to introduce adequate mittees for the prevention of blindness. eye care in underserved communities and A number of bilateral and multilateral agreements were reached in support of 1 WHO Chronicle, 33: 131-134 (1979). 2 Bulletin of the World Health Organization, 57 (5): 3 Week(y Epidemiological Record, 54: 241-280 (1979); 719-734 (1979). WHO Chronicle, 33: 275-283 (1979).

I2I THE WORK OF WHO, 1978-1979 national programmes, with or without prevention, control, and elimination. It direct WHO participation. Regional poli­ dealt in detail with toxoplasmosis, echino­ cies and strategies were formulated in coccosis, cysticercosis, schistosomiasis, four of the six WHO regions, and in five trichinellosis, and larva migrans. A WHO of them national programmes are being informal consultation on mycotic zoonoses developed with the active cooperation of that met in Tel Aviv in I979 discussed WHO. National programmes were formu­ their prevalence and surveillance, preven­ lated in I I countries and are in operation tion, and control. There was also an in eight. Advisory services were provided expert consultation (Warsaw, I978) on the by WHO to I2 countries in I978 and to surveillance, prevention, and control of I4 in I979· cysticercosis/taeniasis and echinococcosis/ hydatidosis. 9· I49 A basic work of reference for the development of national programmes 1 and a guide for the control of xeroph­ Zoonoses centres 2 thalmia were published. Sets of five 9· I 52 Through its headquarters and colour slides with explanatory notes for field staff, including the Pan American the diagnosis of trachoma were prepared Foot-and-Mouth Disease Center in Rio de and distributed. A total revision of the Janeiro and the Pan American Zoonoses guide for the control of trachoma was Center in Buenos Aires, P AHO cooperated begun. with the national authorities and institu­ tions of several countries in planning new 9· I 5o The contribution made to the control and prevention programmes for Voluntary Fund for Health Promotion by zoonoses and exotic diseases, conducting the Japan Shipbuilding Industry Founda­ applied research on vaccines and diagnostic tion (Sasakawa Memorial Health Foun­ procedures, and training staff in various dation) for the prevention of blindness fields of veterinary public health and (US$ 200 ooo in I 978) made it possible, animal health. Several countries, with among other global activities, to hold a close technical cooperation from the Zo­ working group and to support national onoses Center, carried out control pro­ programmes in South-East Asia and the grammes for brucellosis, bovine tuber­ Western Pacific. culosis, hydatidosis, leptospirosis, and rabies. Studies using mathematical models Veterinary public health were conducted during I978 and I979 to evaluate various strategies for controlling 9· I 5I The WHO Expert Committee animal diseases and to determine the on Parasitic Zoonoses which met in Geneva economic loss caused by brucellosis, bovine in I978 3 with the participation of FAO, tuberculosis, hydatidosis, and tick infesta­ reviewed the socioeconomic aspects and tion. Extensive field trials carried out by factors influencing their prevalence and the Foot-and-Mouth Disease Center showed recommended measures for surveillance, that oil adjuvant vaccines against foot-and­ mouth disease considerably reduce pro­ 1 World Health Organization. Guidelines for pro­ gramme costs and increase the immunity grammes for the prevention of blindness. Geneva, 1979. of young animals. The Zoonoses Center 2 Sommer, A. Field guide to the detection and control of also performed experiments with an easy­ xerophthalmia. Geneva, World Health Organization, 1978. to-prepare economical rabies vaccine pro­ 3 WHO Technical Report Series, No. 637, 1979. duced in tissue culture.

I22 COMMUNICABLE DISEASE PREVENTION AND CONTROL

9· I 5; The Mediterranean zoonoses con­ criteria for raw meat and poultry or for trol programme, the principal centre of raw foods in general as they were not which is in Athens, began on I February considered to be of any significance for I979· Five countries-Bulgaria, Egypt, the protection of human health. Greece, the Libyan Arab Jamahiriya, and Turkey-participate, but other countries 9· I 58 The work carried out jointly on the Mediterranean have shown interest with F AO on an international code of and have already collaborated with the principles for ante-mortem and post­ centre in some specific fields. mortem judgement of slaughter animals and meat continued and a draft was 9. I 54 Cooperative efforts with OA U finalized by a group of experts in I979· resulted in plans for at least two zoonoses The document will be submitted to the centres for east and west Africa. They Codex committee on meat hygiene and if were endorsed by the meeting of the OA U approved wil be passed to the Codex Council of Ministers and the Economic Alimentarius Commission for final en­ Commission for Africa (Nairobi, I979)· dorsement.

9·I5 5 In I979 WHO convened two 9· I 59 In addition to the existing WHO meetings, one in New Delhi for countries collaborating centre on food virology at in South-East Asia and the other in the Food Research Institute, Madison, Istanbul for countries participating or Wisconsin (United States of America), a showing interest in joining the Mediter­ second centre was established at the ranean zoonoses control programme. At Veterinary Research Institute, Brno these meetings planning procedures, the (Czechoslovakia). The centres collect, selection of suitable methods for the evaluate, and make available data on the control of zoonoses and foodborne dis­ characteristics of viruses. eases, and the execution and evaluation of national projects were reviewed in Contribution of veterinary public health to detail. primary health care

Surveillance offoodborne diseases 9.I6o Consultations held by WHO with the participation of FAO (Moscow, July 9·15 6 An international surveillance pro­ I979) reviewed the role of veterinarians in gramme of foodborne infections and intoxi­ public health, the importance of their cations to aid national control programmes activities for national primary health care was started in the European Region. programmes, and ways and means of A meeting of representatives of countries strengthening their contribution. in Europe was held (Geneva, April I979) to discuss implementation of the pro­ Training in prevention and control of zoonoses gramme. A manual for food inspectors and foodborne diseases was developed by WHO in collaboration with FAO. 9.I6I Teaching of these subjects at undergraduate and postgraduate level was 9·I57 An FAO/WHO working group reviewed at a WHO interregional seminar met in Geneva in I979 and amended draft on manpower development in veterinary general principles for the establishment of public health (New Delhi, I978). It recom­ microbiological criteria for foods. It mended substantial strengthening of both decided not to recommend microbiological the medical and the veterinary curriculum.

Iz; THE WORK OF WHO, 1978-1979

The same recommendation was made at tion were prepared and distributed to more the fourth meeting of the F AO/WHO than 3 5o institutions throughout the world expert consultation on veterinary education through the WHO collaborating centre (Uppsala, Sweden, 1978). for worldwide reference on comparative oncology, Washington. 9.162 Coordination of international postgraduate training courses in food 9.166 Through the network of WHO microbiology for students from developing collaborating centres for defined laboratory countries resulted in integration of the animals, Member States in the past two activities of the four training centres in years received more than IOoo breeding Europe participating in this programme. nuclei of various strains and stocks of The present trend is to run the courses in defined laboratory animals for the estab­ developing countries. Thus a WHO lishment of their own animal colonies. intercountry workshop on advanced micro­ Research work on the development of new biological methods in food hygiene was animal models is constantly being under­ held in India in I979· taken and new strains of animals were added to the earlier stocks. The cryo­ 9.163 The Pan American Foot-and­ biological technique introduced in the Mouth Disease Center and the Pan Ameri­ can Zoonoses Center offered a wide range centres permits the establishment of frozen of workshops, courses, and seminars with embryo banks of mice strains and thus the storage of standard strains for many years the participation of hundreds of profes­ without change in their genetically stable sionals from all countries in the Americas.1 condition. The centres held consultations and conducted training programmes in Comparative medicine laboratory animal medicine and husbandry for personnel from many different coun­ 9.164 Two WHO consultations (Ge­ tries. A WHO consultation on laboratory neva, 1978 and 1979) reviewed naturally­ animal medicine (Carshalton, United King­ occurring tumours in large animals (mostly canine) as models for cancer in man and dom, 1978) reviewed collaborative work and planned the future development of the histological diagnosis, prognosis, and the programme, in respect especially of clinical staging of animal tumours in relation to neoplasia in man. The con­ technical cooperation with developing sultations also formulated plans for col­ countries. laborative clinical trials on the treatment 9· 167 PAHO cooperated with Brazil, of canine osteosarcoma and mammary Colombia, and Peru in their programmes carcinoma and coordination of the results, to breed the American nonhuman and prepared staging forms (27 in number) primates most used in biomedical research. for the most important animal tumours The Peruvian primate centre at Iquitos of interest in comparative medicine. now has four large monkey shelters. 9.165 Under the WHO project for the 9· I 68 Many new strains of myco­ creation of an international histological plasma and virus isolated from animals classification of tumours of domestic ani­ were characterized and new reference 2 mals, study sets of Part II of the classifica- strains and standard sera prepared within

1 the framework of the F AOjWHO pro­ See also Chapter 12, paragraph 12.II3. grammes on comparative mycoplasmology 2 Bulletin of the World Health OrganizatiOit, 53 (2-3) : 137-304 (1976); 56 (3): 377 (1978). and comparative virology. In Freiburg COMMUNICABLE DISEASE PREVENTION AND CONTROL

(Federal Republic of Germany) the board 9·171 Past and future developments of of the programme on comparative myco­ the programme were discussed and the plasmology in 1978 discussed recent devel­ data updated by WHO workshops (Beth­ opments and accepted new reagents pre­ esda, United States of America, 1978). 1 pared by the working teams of the pro­ gramme and WHO in consultation with the WHO collaborating centre for com­ Vector biology and control parative mycoplasmology in Aarhus (Den­ mark). 9.172 A complete reorientation of WHO's approach to vector biology and 9.169 At a WHO/FAO consultation on control is taking place, with emphasis on comparative virology (Rome, 1979) the the problems of tropical rural areas and programme was revised and strengthened on the need to involve communities in by the establishment of a new organiza­ their own protection. The objective is to tional structure and priorities with more develop regional and national self-reliance practical targets. An inventory of reference by strengthening training facilities, im­ reagents prepared within the programme proving information, and cooperating with was drawn up and a repository for the national administrations in the planning reagents established at the WHO collabo­ of sound vector control programmes within rating centre for veterinary public health the basic health services. in Brno (Czechoslovakia). Ecology and chemical control 9· 170 Collaboration in the WHO ex­ panded programme on the study of the 9.173 Vector resistance. The situation ecology of influenza in animals now has deteriorated further with the develop­ covers approximately 90 laboratories in ment of resistance to malathion by Ano­ different parts of the world. Many different pheles stephensi in Iran and A. arabiensis in species of animals, including domestic Sudan and to DDT by A. minimus in and wild birds, were examined. From northern Thailand. Resistance mechanisms them, and especially from birds, many that reduce the effectiveness of fenitrothion influenza A viruses with new combina­ usually do the same with malathion. tions of H and N antigens were isolated and However, a population of A. sacharovi in characterized. Among these viruses were Turkey is resistant to fenitrothion and strains resembling different variants of some other organophosphorus compounds the current Hong Kong subtype (H3Nz) but not to malathion. In this irrigated from pigs and birds, showing that human area the pressure of agricultural insecti­ influenza viruses continue to circulate in cides has given rise to fenitrothion resist­ nature. Influenza viruses were isolated ance without so far materially reducing from the water in lakes inhabited by wild susceptibility to malathion ; this indicates ducks, from which the same viruses were the need for close surveillance of the use also isolated. Data from China and from of agricultural pesticides in areas of endemic Hong Kong show that chickens possessed vectorborne disease. Malathion and feni­ antibodies against H1N 1 influenza virus trothion are among the few compounds even before the epidemic caused by this that have been recommended for malaria virus began in 1977. H1N1 virus may thus control, and resistance to them can only circulate among poultry in China in the 1 interval before human epidemics. Journal of Infectious Diseases,~ 138 : I Io-I 13 (1978). THE WORK OF WHO, 1978-1979

result in deterioration in the chemical Brugian filariasis and the dynamics of control of important anopheline vectors. transmission. Field trials of five new and improved formulations of insect growth 9· I 7 4 Testing and evaluation of new insecti- regulators for the control of Culex pipiens cides. The number of new insecticides qttinquefasciatus were completed and gave submitted for testing and evaluation by satisfactory control for 8-3 5 days after industry and other sources remains small, treatment. most being pyrethroids. However, there was increased activity during the biennium 9·I78 Vectors of yellow fever and dengue in the evaluation of new formulations and haemorrhagic fever. In Nigeria studies were methods of application of pesticides already completed on the ecology and control of in use, in cooperation with industry and the sylvatic vectors of yellow fever and the collaborating centres, in the Ivory Coast, urban vector Aedes aegypti. Methods for the United Kingdom, the United States of both the ground and the aerial application America, and Upper Volta, and in WHO of insecticides for control during epidemics field research units in Indonesia and are now available. In Indonesia large­ Nigeria. scale studies were started on the control of the larvae of A. aegypti using metho­ 9· I75 Testing and evaluation of equiptJJent prene briquettes in drinking-water. for pesticides. The WHO equipment development and testing programme was 9· I79 Vectors of Japanese encephalitis. expanded to include laboratory testing in In view of the recent outbreak of Japanese four international collaborating centres encephalitis in India, assistance was pro­ and field testing in a number of national vided for an interregional meeting held programmes. Some 55 laboratory and in New Delhi. field tests were carried out in I978 and I979, many indicating the need for manufacturers 9.I8o Vectors of onchocerciasis. WHO to improve their equipment. cooperated with Guinea, Guinea-Bissau, Mali, Nigeria, and Senegal and, in cooper­ 9·I76 Vectors of malaria. Studies on ation with DANIDA, with the United the ecology of Anopheles aconittts and Republic of Tanzania in the planning of its control were continued by WHO in onchocerciasis control campaigns. It par­ Indonesia. In the Syrian Arab Republic, ticipated in an evaluation mission in and Turkey the national authorities, with Guatemala and Mexico. Priority was WHO collaboration, carried out ultra­ given to the development of new larvicides low-volume applications of insecticides for controlling onchocerciasis vectors in the against malaria vectors in important foci onchocerciasis control programme areas. and assisted in conducting field trials using newer insecticides. WHO also 9. I 8 I Vectors of trypanosomiasis. Assist­ collaborated with national authorities in ance was given to the Special Programme vector control planning and evaluation for Research and Training in Tropical in Algeria, Haiti, Solomon Islands, Sudan, Diseases in the planning of the aerial and Turkey. application of insecticides to a sleeping sickness focus in the I vary Coast. 9· 177 V11ctors of filariasis. Studies con­ tinued on filariasis transmission in Java 9.I82 New methods of ultra-low­ and the outer islands of Indonesia, par­ volume application of insecticides against ticularly on the ecology of the vectors of riverine tsetse flies were developed in the

126 COMMUNICABLE DISEASE PREVENTION AND CONTROL

Ivory Coast and Upper Volta. Close of collaborating centres endorsed the re­ cooperation was maintained with outside orientation of the scheme for testing and groups carrying out feasibility studies on evaluating new pesticides to bring it into the genetic control of Glossina. Special line with industrial developments and to emphasis was also placed on the develop­ adapt it to the needs of Member States. ment of simple control methods against The same theme was developed more the tsetse fly that could be used by rural specifically at a meeting of experts with communities for their own protection in representatives of industry to stimulate sleeping sickness endemic areas. research on formulations for blackfly con­ trol in the onchocerciasis control pro­ 9.I83 WHO participated in the evalua­ gramme. At its third meeting in I 978 the tion of a research project on the release of WHO Expert Committee on Vector Bio­ sterilized males of Glossina palpalis gam­ logy and Control advised on the safe use biensis in the Upper V alta. of pesticides newly developed for public health use.l 9.I84 Rodent and plagtte control. The Rodent Control Demonstration Unit in 9.I88 The problem of hazardous con­ Rangoon continued its studies on the centrations of toxic impurities in malathion control of rodents in Burma. Two new anti­ water-dispersible powder formulations is coagulant rodenticides were found to be being faced by vector control authorities effective at such low dosages that their in many tropical countries. WHO col­ use is likely to be economical and highly laborated with countries in arranging the effective. Plans were begun for a large­ testing of field samples and in providing scale field trial to determine the most guidance on the safe use or disposal of effective methods of rodent control in affected formulations. various areas of Rangoon. 9· I 89 To assist Member States in or­ 9. I 8 5 At the request of Indonesia, dering pesticides for public health use, studies were carried out on potential a new edition of the specifications manual 2 rodent reservoirs of plague, the control was published in I979· A new mechanism of rodent fleas, and rodent reservoirs of for the distribution of interim specifica­ scrub typhus on the outer islands. tions was devised to ensure that all those needing them, particularly in developing 9.I86 Schistosomiasis. WHO collabo­ countries, will receive them. rated in the planning of studies of the distribution and control of the snail 9·I9o A feasibility study on the pro­ intermediate hosts of schistosomiasis in vlslon of a central consultative service on several countries or areas, including Congo, pesticides (and later on toxic substances) Morocco, and the United Republic of for countries and territories in the South Tanzania (Zanzibar). Training brochures Pacific area showed that this may be a for the identification of the snail host in pattern of organization that could en­ West Africa were prepared. Research was courage harmonization of pesticide control. also supported on the screening of new 9·I9I A training course on the safe potential molluscicides, including those of use of pesticides was developed that 1s natural origin. 1 WHO Technical Report Series, No. 634, 1979. 9· I 8 7 Pesticide prodttction, formulation, 2 World Health Organization. Specifications for and safe 11se. A meeting of the directors pesticides used in public health, 5th ed. Geneva, 1979.

I27 THE WORK OF WHO, 1978-1979 adaptable to varying levels of health a sex-linked propoxur resistance gene was workers, including basic health workers, successfully developed. When the larvae and to national requirements. Full versions are dipped into a solution of this insecticide, of the course were prepared for Egypt susceptible females are killed but resistant and Nigeria. males survive.

Biological control Environmental control 9·I92 Some entomopathogenic strains 9· I 96 The frequent increase in vector­ of bacteria, fungi, and microsporidia have borne diseases in irrigated areas needs to shown promise in laboratory trials of being be borne in mind in water resources pro­ useful for the control of vectors. Data jects and measures for their prevention sheets were prepared on them for wide and control need to be envisaged. A distribution. Collaborative laboratory memorandum of understanding was signed studies on the efficacity of these agents between WHO and F AO on collaboration and on their safety for mammals and non­ in the prevention and control of water­ target organisms were intensified in both borne and associated diseases in agri­ developed and developing countries and cultural water development activities in in WHO research units. Small circum­ December I977/January I978. A seminar scribed field trials started. Large-scale held in Alexandria and Sudan in I978 trials await the completion of safety tests. reviewed these problems in irrigated areas. 9·I93 The use of larvivorous fish in 9·I97 The first meeting of the Expert the control of malaria was investigated in Committee on Environmental Manage­ Somalia. Two local species, Tilapia zilli ment for Vector Control was held in and Nothobranchius palmquisti, were identi­ November I979· As a result, a manual fied and a small-scale trial on Tilapia zilli on environmental management for vector was started in a man-made reservoir in a control with special emphasis on malaria semi-desert area of Somalia. vectors is being prepared.

9·I94 A travelling seminar on the use Vector control in international health of larvivorous fish for mosquito control in antimalaria campaigns was held in Bulgaria 9· I98 The use of the propellant chloro­ and the USSR. Recent developments in :fluoroalkanes in aerosols for the disin­ biological control and the taxonomy, eco­ secting of aircraft has been criticized logy, biology, and use on a global basis because of the possible depletion of ozone of larvivorous fish were reviewed. Field at high altitudes. A WHO collaborating visits enabled the participants to see for centre carried out tests on aerosols based themselves the effectiveness of this method on propellants other than chloro:fluoro­ of malaria control in certain situations. alkanes and on waterbased formulations. These techniques are being further per­ Vector genetics and genetic control fected.

9·I95 One of the major difficulties in Training and dissemination of information research on the genetic control of mos­ quitos has been the sexing of mosquitos 9· I 99 In collaboration with national at an early stage to avoid the liberation of authorities and the Special Programme females. A genetic sexing technique using for Research and Training in Tropical

128 COMMUNICABLE DISEASE PREVENTION AND CONTROL

Diseases, a special effort was made to eases as one of the eight elements necessary organize and support a series of MSc to provide health care to the world's courses in medical entomology and vector population by the end of the century. control in three WHO Regions (Africa, the Americas, and South-East Asia), and 9.203 The number of countries and steps are being taken to do the same in territories that have indicated their com­ a fourth, the Eastern Mediterranean Re­ mitment to the Expanded Programme on gion. Training courses supported by Immunization rose from 35 in I977 to grants from the Governments of Denmark 99 in I 979, representing more than 9 5 % and the Federal Republic of Germany of the neonates in the developing world. were organized in Iraq, Ivory Coast, and These 99 countries are collaborating with Liberia on rodent biology and control, WHO in reviewing their immunization urban mosquito control, and the aerial coverage and formulating plans that will application of insecticides against tsetse provide for the rational expansion of flies. Training brochures on vector biology existing services or the development of and control were produced and the pre­ new services. Problems common to most paration of slide sets for use in regional countries include lack of planning and and national training courses began. management skills and absence of data on which to base programme strategies 9.2oo The Regional Office for the and evaluate progress. Eastern Mediterranean established a re­ gional training centre for malaria and Planning, training, and inforntation systems vector biology and control, in collabo­ ration with the Government of Iraq. 9.204 The Global Advisory Group on 9.2oi The Western Pacific Regional the Expanded Programme on Immuniza­ Office provided training in control for tion met in Geneva in I 978 and in New health inspectors and related staff from Delhi in I 979 to review progress and American Samoa, the Cook Islands, French advise on plans concerning strategies, Polynesia, Malaysia, Niue, the Philippines, programme implementation, and research the Republic of Korea, and Samoa. and development. National training courses were held in the 9.205 Planning and management train­ Republic of Korea and in-service training ing was given in I979 to 872 national and during field activities was provided for international staff from more than I oo Malaysia, the Philippines, and a number countries. Stress was placed on such of South Pacific countries or areas. health management concepts as the setting of priorities and objectives, performance supervision, evaluation, and community Expanded Programme on Immunization participation. In the critical area of cold­ chain management a series of visual aids 9.202 In I978 the Thirty-first World were provided, including slide sets, posters, Health Assembly emphasized the import­ and simple publicity material. ance of immunization as a component of health programmes such as maternal and 9.206 Between 5o% and 70% of coun­ child health and primary health care tries report the number of cases of one (resolution WHA31.53). In the same year or more of the Expanded Programme's the Declaration of Alma-Ata named immu­ target diseases, and reports on immu­ nization against the major infectious dis- nizations are received from less than 30%. THE WORK OF WHO, 1978-1979

Initiatives were therefore undertaken to to improve the stability of both live improve reporting systems. poliomyelitis vaccine and the pertussis component of diphtheria/pertussis/tetanus 9.207 Progress was recorded in the vaccine. Increase of potency is of special establishment of a system, developed jointly importance for vaccines requiring more with UNICEF, for projecting future vaccine than one dose, and one of the major requirements and in the distribution research efforts during the period was through UNICEF of product information directed towards increasing the potency sheets which supply performance and cost of pertussis vaccine and reducing the data on commonly used equipment. News­ incidence of adverse reactions. letters on the programme were begun. Abstracts of scientific articles relevant to 9.2Io Regional meetings in Africa and immunization are being prepared in English South-East Asia were held to discuss the by the Center for Disease Control, Atlanta, quality control of vaccines, their produc­ USA, and in French and English by the tion, and their distribution on an inter­ International Children's Centre, Paris ; country basis. With UNDP support, they are mailed to 5oo persons involved 66 national laboratory staff were trained in the programme. in various aspects of vaccine quality control. The rationalization of future production Research and development and distribution has been a joint concern of WHO and UNICEF and resulted in a 9.208 Improving the cold chain. All the WHO regions are now involved in improv­ projection of the vaccine requirements for ing cold-chain management and equipment. developing countries for the coming five­ year period and the development of a The approaches being employed are (I) to test the available equipment in inde­ system to monitor the quality of the provided from all sources. The pendent laboratories and publish the results, vaccines (2) to encourage manufacturers to improve establishment of a P AHO revolving fund current equipment to meet the needs of for the purchase of vaccines assured coun­ tries in the Americas of supplies of ap­ developing countries, and (3) to stimulate the production of equipment in develop­ proved vaccines. ing countries themselves. The results of a major testing of all the items of cold­ 011tside support chain equipment were circulated to those 9. 2 I I The emphasis during the period responsible for their purchase. A special was on cooperation in the planning and vaccine refrigerator designed to operate development of national programmes, and reliably with intermittent electricity supplies the question of direct country programme was produced commercially. In six devel­ support was therefore of lesser priority. oping countries items of cold-chain equip­ UNICEF continued to be the major con­ ment are being manufactured that were tributor to the programme's activities and previously produced in the industrialized extension. countries only. 9.2 I 2 Training activities during the 9.209 Vaccines. WHO-sponsored re­ search supported by UNDP has led to the period would not have been possible commercial production of a more stable without the continuous support received from DANIDA and the Center for Dis­ measles vaccine. 1 Work was carried out ease Control, Atlanta (United States of 1 See also Chapter 8, paragraph 8.3 I. America). Work on vaccines was sup-

130

THE WORK OF WHO, 1978--1979 in the complex task of developing a vaccine now being implemented. The Special or vaccines against malaria. Research Programme organized training courses on ranges from identification of the antigens the in vitro technique for detecting drug on parasites and cell membranes to trials resistance and a contract was awarded for of potential vaccines in animal models. the production of test kits. A new micro­ Advances have been made in test systems technique, recently developed outside the for the detection of circulating antigens, Special Programme, has now been shown and the remarkable new technique for the to offer several advantages. production of monoclonal antibodies is being exploited in an effort to isolate 9.219 Schistosomiasis. The pharma­ particular antigens and assess their role ceutical industry continued to show interest in the induction of immunity. in the development of schistosomicidal drugs and the Special Programme main­ 9.216 In the field of basic biology, tained its support for this development continuous in vitro cultivation of erythro­ effort, especially by clinical evaluation of cytic forms of Plasmodium jalciparum is the new agents. Biochemical studies of increasingly being used as a system for the schistosome resulted in a number of drug susceptibility testing and the screening interesting findings. The mode of action of potential antimalarial drugs, as a source of various drugs and their metabolic of antigen for immunological studies, and pathways are being elucidated; it now as an essential complement of in vivo studies appears that the effectiveness of some, but in animal models. In vitro culture systems not all, antischistosomal drugs is dependent of both erythrocytic and exoerythrocytic upon the immune response of the host. forms of malaria parasites have been 9.220 A workshop on the population improved. Good progress was made in epidemiology of Schistosoma japonicttnJ was the isolation of different stages of the held in the Philippines. Studies began on parasite from infected erythrocytes and of the metabolism of Biomphalaria snails, free parasites, an essential prerequisite for carriers of S. mansoni, on their chemo­ immunological studies. Studies on mem­ receptive mechanisms, and on differences brane structure and function, carbohydrate between strains that are highly susceptible metabolism, and protein synthesis have and those refractory to miracidia! infection. produced valuable leads for further immu­ nological and chemotherapeutic research. 9.221 Filariasis. Clinical research in­ cluded quantitative assessment of the 9.217 A major project on the epidemio­ Mazzoti reaction and means to alleviate it, logy and control of malaria in various investigation of the adverse effects of ecological strata in West Africa continued diethylcarbamazine treatment on posterior to provide data that can be directly trans­ segment eye lesions in onchocerciasis, an lated into malaria control strategies in assessment of reactions to transepidermal corresponding ecological strata in tropical diethylcarbamazine lotions, attempts to Africa. reduce the reactions to the death of micro­ filariae in the cornea, and trials of metri­ 9.218 The resistance of P. falciparum fonate, amodiaquine, furazolidone, and to the 4-aminoquinolines presents a serious nitrofurantoin. The causes of low-grade and urgent problem in malaria control. persistent microfilaraemia after treatment A global programme for the assessment of Wuchereria bancrofti infection with diethyl­ and monitoring of drug susceptibility is carbamazine are being investigated. COMMUNICABLE DISEASE PREVENTION AND CONTROL

9.222 In the search for new filaricides some biochemical features of Trypanosoma more than 970 compounds were screened cruzi which may yield useful leads for the at primary level, and a secondary Oncho­ development of new drugs. Work is in cerca screen in cattle was developed. progress on the standardization of immuno­ Mebendazole and flubendazole appear to diagnostic tests, including the establish­ be promising leads; these compounds may ment of serum reference banks. Other be macrofilaridical and embryostatic, es­ immunological studies concern various pecially if preceded by levamisole. aspects of immune protection and immune pathology. 9.223 Investigations started into the causes and prevention of inflammatory 9.228 Leishmaniases. A modest drug reactions to the death of microfi.lariae in development programme has begun and animal models and in man. Efforts are a protocol for the treatment of muco­ being made to develop in vitro and in vivo cutaneous leishmaniasis was drawn up at culture systems, especially as a source of a workshop in 1979. Epidemiological parasite antigens. studies were initiated in several countries, and some studies were supported on the 9.224 African trypanosomiasis. Drug phlebotomine sandflies. Studies are in screening facilities are being developed in progress on experimental immunization Kenya. Work continued at other centres and the mechanisms of host resistance, on small rodent models. The blocking and on certain leishmania! antigens. These effect of salicylhydroxamic acid and glycerol are necessary steps towards the develop­ is being further investigated. ment of vaccines and improved sero­ diagnostic tests. 9.225 A standard protocol is being developed for autopsies, with particular 9.229 Leprory. The Scientific Working reference to neuropathological examina­ Group on the Immunology of Leprosy has tions, for use in the clinical network that been in operation for over four years. is being established in the endemic areas. Over 300 armadillos have now been More intensive studies on the antigenic inoculated and will provide large quantities repertoire were carried out on isolates of leprosy bacilli. In the past year a new obtained from various sites. technique for the purification of leprosy bacilli was developed ; it provides a high 9.226 A major field research project in yield of bacilli of a high degree of purity West Africa, initiated by WHO before the and the damage during the extraction Special Programme was established, was process is minimal. In animal studies later transferred to it. Among the important killed Mycobacterium leprae, without ad­ advances are confirmation of an animal juvant, were found capable of inducing reservoir of Tryponasoma brucei gambiense, delayed hypersensitivity and of conferring field trials of a new and promising card some protection against infection. Sero­ flocculation test, a new technique for diagnostic tests, including fluorescent anti­ detecting low levels of parasitaemia, and body and radioimmunoassay tests, are being practical information about the effects of developed. aerial spraying of insecticides in control of the tsetse fly. 9.230 Clinical trials of combinations of drugs were begun in India and West 9.227 American trypanosomtasts. Pre­ Africa. The standardized protocol included liminary results have been obtained on the detection of residual bacilli using THE WORK OF WHO, 1978-1979

immunosuppressed rodents. Thirteen drug engineering control in schistosomiasis and development projects are currently under malaria transmission. A workshop was way, including the synthesis, screening, held on methodologies for the study of and study of modes of action of anti­ humanjwater contact. A working group leprotic compounds. met to identify priorities before a meeting of the Scientific Working Group towards 9.23 I · Other scientific Jvorking groups. the end of I979· Signif.icant results have been noted by the Scientific Working Group on Biological Control of Vectors. Perhaps the most Strengthening of research capability exciting development was the promising 9.235 The Research Strengthening results -obtained with certain entomo­ Group developed further the area of the pathogenic bacilli, in particular Bacillus Special Programme aimed at strengthening thuringiensis serotype H-I4. the research capability of the countries concerned. The main features are support 9.232 The Scientific Working Group on to selected institutions in tropical endemic Epidemiology attempts to identify and countries and training for scientists from understand the genetic and environmental those countries. All the activities are factors that determine the prevalence and being developed in close collaboration severity of the six diseases mentioned above, with national authorities and in the context with the aim of providing a rational basis of national needs and resources. During for measures to improve control. This the past year, 59 research fellowships were approach involves a wide range of disci­ awarded, 5 re-entry grants were given, plines, e.g., clinical medicine, laboratory and I9 institutions received support ranging sciences, pathology, statistics, behavioural from a single capital grant to long-term sdences, and economics. The major pro­ support for periods up to 5 years. ject at present is a long-term epidemio­ logical -study based in Zambia. 9.236 A meeting of the representatives of some of the institutions receiving long­ 9'•233 · The aim of the Biomedical Sci­ term support took place to lay the founda­ ences Scientific Working Group is to pro­ tions for institutional self-evaluation. There mote fundamental research on the diseases are already some tangible signs of success. of interest to the Special Programme and For example, as a result of the courses on on their pathogens, and so to develop new continuous in vitro culture of P. falciparum, approaches to methods of diagnosis, thera­ a number of scientists in developing coun­ py, prevention, and control. Workshops tries have now established this technique were held on membrane pathobiology and in their own laboratories and have demon­ cultivation technology. Courses on hy­ strated their ability to teach it to others. bridoma technology with applicability to One of them has made remarkable pro­ parasitic diseases were planned, as well as gress in his attempt to culture other a course ·on micromethods applicable to plasmodial species. research on tropical diseases. 9.237 One feature of the Special Pro­ 9.234 The importance of social and gramme in I979 was the fruitful interaction economic research in achieving the Special between the Research Strengthening Group Programme's objectives has repeatedly been and the scientific working groups. There emphasized. Priority projects in this area have been many examples of research were cbncerned with malaria control and grants providing useful training oppor-

I 34

Chapter 10

Noncommunicable Disease Prevention and Control

Cancer research, which could be used by countries in formulating their policies ; and (c) a simu­ IO.I IN JANUARY I978 the Executive lation exercise in such policy formulation, Board (resolution EB61.R29) en­ carried out in Sri Lanka (September I 979) dorsed the report of its Ad Hoc by a team of national, IARC, UICC and Committee on WHO's Activities in the WHO representatives. This approach Field of Cancer, which recommended inter could lead to a common strategy for alia that the cancer programme at WHO cancer control that can be adopted by headquarters and the programme of the developing countries, and permit effective International Agency for Research on interaction between WHO headquarters Cancer (IARC) should retain their separate and regional offices, IARC, and UICC. identities but should be better coordinated as regards current activities and planning I o. 3 At the XII International Cancer for the future ; and that a coordinating Congress of the International Union committee should be set up to this end, Against Cancer (Buenos Aires, I978), which would deal with high-level policy WHO and IARC took an active part, issues, draw up and evaluate the overall presenting their activities and exhibiting programme, and study problems of over­ their publications. lapping. Histological classification of tumours Io.z The Director-General's Coordi­ nating Committee on Cancer, bringing Io.4 The programme for the Inter­ together representatives of WHO, IARC, national Histological Classification of and the International Union against Cancer Tumours (supported by the United States (UICC), met three times during the bien­ National Cancer Institute) published three nium and considered (a) a situation analysis numbers of the Classification, dealing on cancer, carried out in I978 by a WHO/ with tumours of the upper respiratory IARC team in Sri Lanka and Thailand, tract ;1 liver, biliary tract and pancreas ;2 in conjunction with the Regional Office for South-East Asia, and in Iraq, Kuwait 1 Shanmugaratnam, K. & Sobin, L. H. Histological typing of upper respiratory tract tumours. Geneva, World and Sudan in conjunction with the Regional Health Organization, 1978 (International Histological Office for the Eastern Mediterranean ; Classification of Tumours, No. 19). (b) the formulation by an IARCfUICCf 2 Gibson, J. B. & Sobin, L. H. Histological typing of tumours of the liver, biliary tract and pancreas. Geneva, WHO group (January I979) of guidelines World Health Organization, 1978 (International for national cancer control activities and Histological Classification of Tumours, No. 20). NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL and central nervous system. 1 A compen­ a meeting in 1977); and a handbook for dium 2 linking the histological classifica­ reporting results of cancer treatment was tion with the coding system of the Inter­ published in the same year. 6 national Classification of Diseases for 10.7 Also with a view to promoting Oncology (ICD-0) 3 was also published. uniformity in the collection and recording A meeting was held in December I 978 of data, WHO and IARC, in collaboration to evaluate the utilization of the histo­ with the International Association of Can­ logical classification of breast tumours cer Registries, issued a publication on which was published in 1968,4 and mak~ registration techniques 8 that should im­ recommendations for its updating. Work continued on the definition of precancerous prove comparability of data at both lesions at various sites. national and international level.

Evaluation ofmethods of diagnosis and treatment Traditional medicine 10.8 The resources and potential of 10.5 The WHO collaborating centres traditional medicine for cancer control for the evaluation of methods of diagnosis and treatment of tumours continued their were the object of a WHO consultation reappraisal of diagnostic and therapeutic (November 1978). Particular attention was given to the possible use as anti­ measures. Meetings in 1978-1979 were held on prostate cancer (Stockholm), blad­ tumo.u~ agents of certain plants used by pract1t10ners of traditional medicine and der cancer (Cairo), colorectal cancer (Glas­ gow), and stomach cancer (Tokyo). The to the perspective. this offers for devel~ping countnes mcreasmgly to undertake basic centres dealing with ovarian and gastric cancers published several bibliographies. and clinical research on this matter.

Standardization of reporting Strengthening of national cancer control 10.9. Io.6 Evaluation of the effectiveness of In the African Region the streng­ thenmg of cancer control activities at therapy is often hampered by the lack of country level was facilitated by three sub­ standardization in reporting results of treatment. WHO has promoted a unified regional centres. A preliminary evaluation of hospital-based cancer registries was approach in this area by bringing together carried out in Kenya, Uganda, the United experts to develop an acceptable reporting Republic of Cameroon, and the United system. A meeting on the subject was Republic of Tanzania. Research in col­ held in Brussels in 1979 (the follow-up to laboration with IARC, UNEP and F AO was carried out in Uganda on Burkitt's 1 Ziilch, K. J. Histological typing of tumours of the cen~ral nervous vstem. Geneva, World Health Organi­ lymphoma and on a possible relationship zation, 1979 (International Histological Classification between malaria and the Epstein-Barr of Tumours, No. 21). virus ; and in Swaziland on cancer of the 2 Sob~, L. ~· et .al., ed. A coded compendium of the Internatzonal Hzstologzcal Classification of Tumours. Geneva liver and aflatoxin. World Health Organization, 1978. ' 3 World Health Organization. ICD-0: International 5 World Health Organization. Handbook for reporting classification of diseases for oncology. Geneva, 1976. results of cancer treatment (WHO Offset Publication 4 Scarff, R. W. et al. Histological typing of breast No. 48). Geneva, 1979. tumours • . Genev_a, Wo:ld Health Organization, 1968 6 MacLennan, R. et al. Cancer registration and its (International H1stolog1cal Classification of Tumours techniques. Lyon, International Agency for Research No.2). ' on Cancer, 1978 (IARC Scientific Publication No. 21).

137 THE WORK OF WHO, 1978-1979

I o. I o Eighteen countries in the Region (March I978) to study measures for streng­ of the Americas are participating in a thening cancer control at country level. system for collecting and disseminating WHO also sponsored a seminar on urinary information on cancer research, and during bladder cancer at the National Cancer the period under review nine cancer centres Institute, Cairo (December I978) and a in Latin America were paired with centres seminar on cancer pathology-also in in North America in studies of common Cairo in the same month-in which patho­ interest. A national course on hospital­ logists from IO countries of the Region based cancer registration was held in took part. A similar type of seminar was Costa Rica. held in December I979·

I o. I I In the South-East Asia Region, IO.I5 In the Western Pacific Region more than thirty pathologists from seven the cancer registries in Fiji and Papua countries took part in a seminar designed New Guinea were evaluated as potential to improve the level of histopathological focal points for the development of national diagnosis of tumours and promote uni­ control programmes. A national workshop formity in reporting data (Bangkok, No­ on hospital-based cancer registries was vember I979)· The Regional Office advised held (Seoul, October I978). Emphasis was on cancer registration in Bangladesh ; on also given to the advantages of organizing the formulation of national cancer control tumour boards in major hospitals to super­ programmes in Indonesia and Sri Lanka; vise the management of cancer patients. and on cancer control, including pre­ In I979 WHO and IARC staff members vention, in Thailand. visited China to discuss technical coopera­ Io. I z In the European Region a work­ tion, and three institutes in that country ing group (The Hague, December I978) were chosen to serve as WHO collaborating examined the present state of postgraduate centres for cancers of the nasopharynx, the training in oncology and analysed models oesophagus and the liver. A study group for such training. Its report included a on chronic liver diseases, including cancer, summary of training facilities in cancer was established in Singapore, with the in Europe. A IARC/WHO study group cooperation of WHO and IARC. A work­ (Copenhagen, December I979) discussed ing group on comprehensive cancer con­ the uniform evaluation of a number of trol (Manila, October I979) discussed long-term screening programmes for can­ strategies for control programmes, includ­ cer of the uterine cervix. ing information systems, early detection projects, and health education in cancer. Io. I; In the Eastern Mediterranean Region, the recognition that cancer must be dealt with in the framework of the International Agency for Research on national health care system has led to Cancer 1 several requests for WHO cooperation in Io. I6 IARC carried out its own re­ epidemiology, early detection programmes, search programme into many aspects of and cancer registration. The Regional cancer causation, while at the same time Advisory Panel on Cancer met twice coordinating the work of national institu- (Teheran, March I978; and Karachi, March

I979)· 1 For a more detailed description ofiARC's activities, IO.I4 A WHO team met with national see : International Agency for Research on Cancer, Annual report, I978, Lyon, 1978; Annual report, I979, counterparts in Iraq, Kuwait and Sudan Lyon, 1979. NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL

tions under a series of research agreements. occurring mineral. A meeting (organized The research included studies in descriptive jointly with the Institut national de la and analytical epidemiology, and the inves­ Sante et de la Recherche medicale, France, tigation of chemical carcinogenesis and and the pneumoconiosis unit of the British tumour-associated antigens. The training Medical Research Council) reviewed re­ programme (see paragraphs I0.37-I0.39 search on the biological effects of man­ below) is integrated with the research made mineral fibres. The physics and act1v1t1es. Sweden became a Participating chemistry of dust, comparative and human State of IARC in I979· pathology, clinical and radiological diag­ nostics, and particularly epidemiology, were I o. I 7 Directories of current research considered in relation to both man-made in cancer epidemiology were again pub­ mineral fibres and asbestos. lished, jointly with the Cancer Research Centre, Heidelberg, Federal Republic of Germany, in I978 and I979,l· 2 the latter Alcohol consumption and cancer volume containing Io92 entries reported from 67 countries indexed by key-word, I0.20 The relationship between con­ tumour site, epidemiological method used, sumption of various types of alcoholic country, and incriminated chemical in the beverage and a variety of diseases-notably case of exposure studies. cancer, cirrhosis of the liver, and coronary heart disease-was investigated. In studies IO.I8 Work continued on Volume IV in Brittany and Normandy (France), a of Cancer Incidence in Five Continmts, cover­ dosejeffect response was clearly shown for ing the period I973-I977 and including oesophageal cancer in relation to various data from over So populations. beverages consumed (expressed as grams of ethanol) and to a lesser degree for tobacco Hazards of man-made mineral fibres consumption, the two agents acting syner­ IO. I9 The programme on health hazards gistically. associated with the man-made mineral I o. 2 I A cohort study of Danish brewery fibres industry continued satisfactorily, workers showed excessive mortality from despite the absence of cancer registration cancers of the oesophagus and pharynx, in many countries and, in some, the dif­ but also from cirrhosis of the liver, gastro­ ficulty of linking death certificates with , duodenal ulcers, and road traffic accidents. factory records of exposure. The study was extended to users of such fibres, I0.22 The relationship between cancer particularly in the building industry in of the larynx and alcohol consumption, Sweden. A related study continued in tobacco-smoking, diet, and certain indus­ central Turkey, where a high but extremely trial exposures was studied in France, localized incidence of mesothelioma appears Italy, and Spain-countries where morta­ to be related to the presence of a naturally- lity from this type of cancer has been rising over the past 20 years. 1 Muir, C. S. & Wagner, G., ed. Directory of on-going research in cancer epidemiology, I978. Lyon, International Agency for Research on Cancer, I978 (IARC Scientific I0.23 The possible role of alcohol Publications, No. 26). consumption and diet in cancer of the 2 Muir, C. S. & Wagner, G., ed. Directory of on-going rectum was studied in Belgium, in view research in cancer epidemiology, I919· Lyon, International of the difference in risk observed between Agency for Research on Cancer, 1979 (IARC Scientific Publications, No. 28). the north and south of the country. THE WORK OF WHO, 1978-1979

10.24 The presence of carcinogenic from patients with cancer of the liver, chemicals in alcoholic beverages from cirrhosis, or miscellaneous liver diseases several sources continued to be examined in 16 countries. Preliminary findings by analysis of fractional distillates, com­ confirm the results of the serological bined with mutagenicity testing and animal studies. experiment. Although data from Normandy would seem to indicate that apple cider 10.27 A cohort study of carriers of distillates are more carcinogenic than other these viral surface antigens was initiated beverages, the quantity of ethanol con­ in the Chinese population of Singapore, sumed, irrespective of source, is still the its object being to determine the risk of best risk indicator. developing liver cancer among carriers of the antigens and compare it with the risk Cancer of the large boJVel among non-carriers. A prevalence survey of antigenic serological markers of hepa­ 10.25 Cancer of the large bowel is now titis-B virus infection was planned in three the second most frequent cancer for both regions of Swaziland, where previous sexes in several industrial countries and is IARC studies had demonstrated an increas­ increasing in parts of Asia, where it has ing risk of liver cancer associated with the hitherto been rare. There is general agree­ degree of aflatoxin exposure. A study was ment that diet may be responsible, though also begun, in collaboration with UNEP probably indirectly. Since the presence of and F AO, with a view to developing a cancer may influence dietary habits, measures for decreasing aflatoxin conta­ various aspects of digestive tract physiology mination in these areas. were investigated in healthy subjects in rural Finland and urban Denmark, two areas where the risk of cancer of the large Burkitt's !Jmphoma bowel has increased four-fold. The results 10.28 The study on Burkitt's lymphoma obtained so far tend to favour the hypo­ in children of the West Nile district of thesis that the ingestion of dietary fibre Uganda showed that infection with the protects against this cancer. These findings Epstein-Barr virus played a causal role. may reflect other differences in life style But clearly other factors must be involved. specific to the Nordic countries; similar In collaboration with the malaria action pro­ investigations will therefore be carried out gramme at headquarters, the Agency is in countries with a wide range of incidence therefore studying the effect of elimination of cancer of the large bowel but with of malaria on the incidence of Burkitt's contrasting backgrounds, e.g., France and lymphoma in an area of the United Re­ Colombia. public of Tanzania.

Cancer of the liver Nasopharyngeal carcinoma 10.26 The association between chronic persistent infection by hepatitis-B virus 10.29 Study of the sera of nasopharyn­ and primary cancer of the liver has been geal carcinoma patients showed the presence demonstrated in several serological case­ of a specific immunoglobulin, IgA, related control studies. It is being examined antigenically to the Epstein-Barr virus. further in a prevalence study of hepatitis-B Elevated IgA levels were also found in viral surface antigens in fixed liver tissue patients suffering from bronchial carcinoma.

J40 NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL

Tumour-associated antigens 10.33 Studies were carried out in col­ laboration with a number of national 10.30 The Agency continued to dis­ laboratories on the in vitro and in vivo tribute the international standard for alpha­ interaction between carcinogens and bio­ fetoprotein. In studies in six laboratories, logically significant molecules, especially the activity of the international unit was DNA, with a view to increasing know­ found to be equivalent to I.2I ng of ledge on the problems of extrapolating alpha-fetoprotein. from the results of animal experimentation

10.3 I In collaboration with the National to man. Institute for Biological Standards and 10.34 Efforts were continued to im­ Control, London, a reference material was prove the efficiency of screening tests for prepared for the assay of betacspecific­ putative carcinogens, such as mutagenicity pregnancy-glycoprotein, the level of which and other short-term assays using both is increased in the blood of patients with bacterial and mammalian cells. hydatidiform mole or choriocarcinoma. Three collaborative studies are under way I o. 3 5 Collaborative analytical studies to compare the antigens associated with were established with 22 laboratories in carcinoma of the lung, the ovary and the I o countries, to improve methods for the breast. determination of nitrosamines in foods and beverages. The methods were applied Chemical carcinogens to the analysis of alcoholic beverages in studies on oesophageal cancer in France ; I0.32 Five international working and the samples were tested in parallel for groups met in Lyons during I978-I979 their mutagenicity. to evaluate published data covering I03 10.36 The first three volumes on se­ chemicals. Their proceedings resulted in lected analytical methods for environ­ volumes I9-23 of the IARC Monographs mental carcinogens were published, cov­ on the Evaluation of the Carcinogenic ering volatile nitrosamines, vinyl chloride, Risk of Chemicals to Humans, volumes I9 and the polycyclic aromatic hydrocarbons. 2 and 20 of which were published, 1 while Volumes have also been prepared on volumes 2 I, 22 and 2 3 (dealing respectively laboratory disposal of carcinogens, and the with natural and synthetic sex hormones ; problems of safety in the handling of cyclamates and saccharin; and some metals) carcinogens in the laboratory. were in press at the end of I979· A working group reviewed the monographs published Traini1zg in volumes I-2o of this series, and listed 36 chemicals or industrial processes for 10.37 The demand for tra1mng in which there was evidence of an associa­ cancer epidemiology continued to be met tion with cancer in man, and a further by the award of one-year fellowships and I I 8 chemicals suggested by the data from animal experiments to present carcinogenic 2 International Agency for Research on Cancer. risk for man. Environmental carcinogens : Selected methods of analysis. Volume I - Analysis of volatile nitrosamines in food. Lyon, 1978 (IARC Scientific Publications, No. 18); 1 International Agency for Research on Cancer. Volume 2 - Methods for the measurement of vitryl chloride !ARC monographs on the evaluation of carcinogenic risk in poly(vitryl chloride), air, water and foodstuffs. Lyon, of chemicals to man, Volume 19 - Some monomers, plastics 1978 (IARC Scientific Publications, No. zz) ; Volume J­ and ~nthetic elastomers, and acrolein, Lyon, 1978; Volume Polycycli• aromatic hydrocarbons. Lyon, 1979 (IARC 20 - Some halogenated hydrocarbons, Lyon, 1979. Scientific Publications, No. 29). THE WORK OF WHO, 1978-1979

by short courses for selected specialists. programmes on comprehensive community Such courses, lasting 2.-4 weeks and control of cardiovascular diseases. These attended by an average of 40 participants, pilot areas cover more than 7 million were held at the Agency's headquarters inhabitants in 2. 3 countries, I I of them and also in Brussels, Sydney and Beijing developing countries. A preliminary analy­ (Peking), the latter in collaboration with sis of the results obtained shows that it is the Regional Office for the Western possible by the community approach to Pacific. decrease the various risk factors and favourably influence the incidence of certain 10.3 8 In the fellowships programme, cardiovascular diseases, specifically stroke. preference was given to applicants working on environmental carcinogenesis. Of the 10.43 At the request of the respective 2.5 fellowships awarded during the bien­ governments, visits were made to I o nium, eight were for training in cancer African countries to identify institutes and epidemiology. persons who could assist in developing I0.39 Scientists from Io countries were national programmes in cardiovascular trained in the Agency's laboratory in diseases. I978-I979· 10.44 At theWorld Congress of Cardio­ I978) 1 logy (Tokyo, September a special Cardiovascular diseases symposium was held on WHO activities 10.40 In I978, a long-term programme in this field. Similar symposia were held in cardiovascular diseases-involving head­ during the last two European Congresses quarters and all regional offices-was of Cardiology, and at the Asian-Pacific formulated. As a first step in its imple­ Congress of Cardiology (Bangkok, Novem­ mentation, work began under the medium­ ber I979)· term programme for I978-I983, whose principal objective is to develop and test methods that will enable public health Hypertension authorities to establish programmes for I 0.4 5 The Expert Committee on the prevention and control of cardio­ Arterial Hypertension, meeting in Geneva vascular diseases as an integral part of in March I978, recommended that national existing health services. public health authorities should give 10.4I A plan of action for primary prompt attention to this disease, which (primordial) prevention of cardiovascular affects at least 8 % of the adult population diseases in developing countries with the in most countries. The Committee's aim of preventing the development of risk report 2 outlined the present state of factors was discussed by a meeting of knowledge of hypertension, and the means investigators, to which representatives of for assessing its gravity and for treating other organizations in the United Nations patients ; made suggestions for a com~ system were invited (Geneva, December munity approach to prevention and control I978). in countries with different types of health care systems ; and recommended appro­ 10.42. Regular meetings were also held priate research. of the principal investigators in the pilot

1 See also Chapter 12., paragraph 12..117. 2 WHO Technical Report Series, No. 6z8, 1978. NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL

I 0.46 In collaboration with several over the past few years the importance of members of the Expert Committee, a the community approach. Strategies for manual on the control of hypertension was expanding pilot projects to nationwide prepared that should help health personnel preventive and control programmes were at the community level to deal with the defined at an interregional meeting (New problems encountered in daily practice. Delhi, November I979)·

10.47 The WHO project on the control Jschaemic heart disease of hypertension in the community, which covers 30 ooo patients in 2 3 population 10.5 I In I978-I979 there was a sudden, areas (I 5 of them in developing countries), but not unexpected, demand for a reliable was evaluated in I979 in certain of the system to monitor the incidence of ischae­ centres, the final assessment being planned mic heart disease, the main reason being for I98o. In addition a large therapeutic a reported steep decline in mortality from trial on the control of mild hypertension this cause in the United States of America was completed jointly with the Interna­ and to a lesser extent in Australia, New tional Society of Hypertension; the result­ Zealand, and some other countries. In the ing data were considered at a meeting of absence of relevant data, it is impossible the liaison committee (Japan, September to explain these trends. Registers of acute I978). myocardial infarction were examined, and a new monitoring system is being designed : 10.48 A meeting of Member States of a group of consultants (Geneva, Septem­ the European Region (Copenhagen, Oc­ ber I979) prepared a plan of operations tober I979) established policies for health­ for the study and the draft protocol was care-related research on hypertension in discussed at a preliminary meeting of that Region (see also Chapter 4, paragraph investigators in December I979· 4·30). IO.p The trial on primary prevention I0-49 The theme of the World Health of ischaemic heart disease by administration Day in I978 was "Down with high blood of the lipid-lowering drug clofibrate, com­ pressure". In collaboration with the pleted in I977, established that by lowering International Society and Federation of the serum cholesterol the incidence of Cardiology (ISFC) an extensive informa­ ischaemic heart disease decreases by as tion programme was launched, which in much as 20%. In view of certain side many countries was instrumental in pro­ effects of clofibrate, its use is not recom­ moting long-term programmes for control mended for community-wide primary pre­ of hypertension at community level. vention. The centres conducting the trial are following up all subjects participating Rheumatic fever and rhet1matic heart disease in the study in order to monitor the long­ term effects of the drug. 10.50 The programme for the preven­ tion and control of rheumatic fever and Thrombosis rheumatic heart disease focuses principally on the populations of the developing 10.5 3 Contacts were established with the world. A WHO project in 20 countries ISFC Scientific Council on Thrombosis, the of Africa, Latin America, South-East Asia European Thrombosis Research Organ­ and the Western Pacific has demonstrated ization, and the Commission of the Euro- THE WORK OF WHO, 197S--1979 pean Communities for a collaborative centre for studies on physical activities in research project to assess the tendency to relation to cardiovascular diseases. thrombosis in relation to the complications of ischaemic heart disease. Trace elements

Atherosclerosis 10.58 The JOint IAEA/WHO research project to ascertain whether trace element 10.54 A working group on athero­ imbalances play a role in the etiology of sclerosis precursors and determinants in myocardial infarction was completed in children (Geneva, September 1979) re­ 1979 and the final statistical evaluation is viewed the methods used and the results being undertaken. Some 20 centres­ obtained in two WHO pilot programmes in Bulgaria, Denmark, the Federal Republic and defined possible action for primary of Germany, Hong Kong, Nigeria, Norway, prevention. the Philippines, Singapore, Sweden, Swit­ zerland, the United Kingdom, and the Life sryle factors United States of America-had collaborated in the project. 10.5 5 The report of a WHO Expert Committee on Controlling the Smoking Standardization in nomenclature, diagnostic Epidemic, 1 which met in October 1978, criteria and methods was one of the main documents before the Fourth World Conference on Smoking and 10.5 9 The task forces on this subject Health (Stockholm, June 1979). The established in collaboration with ISFC Conference was cosponsored by WHO, continued their work. The reports of the and an advisory committee was established Task Force on Classification of Arrhythmias under its aegis for the follow-up of inter­ and of the Task Force on Nomenclature national action resulting from the Con­ and Criteria for Diagnosis of Ischaemic ference. Heart Disease were issued and were later translated by various national cardio­ 10.56 Preparations were made for logical societies into their own languages. World Health Day 1980, the theme of which is : "Smoking or health, the choice At the end of 1979 the proposals made by the Task Force on Classification of Cardio­ is yours". myopathies were being reviewed by experts 10.5 7 A monograph on the role of nominated by national cardiological so­ habitual physical activity in relation to cieties. health was published by the Regional Office for Europe ;2 closer collaboration with the International Federation of Sports Other chronic noncommunicable Medicine was established ; and the Insti­ diseases tute of Work Physiology, University of Dortmund (Federal Republic of Germany) 1o.6o During the biennium the com­ was designated as a WHO collaborating munity approach was the cornerstone of WHO's programme in many of the chronic 1 WHO Technical Report Series, No. 636, 1979· noncommunicable diseases. Following the 2 Lange Anderson, K. et al. Habitual physical activity recommendations of the International Con­ and health. Copenhagen, World Health Organization, ference on Primary Health Care (Alma­ 1978 (WHO Regional Publications, European Series No.6). Ata, 1978) and evaluation of experience

144 NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL with chronic disease control in the com­ ly organized a postgraduate course on munity, there was a growing acceptance diabetes (Nairobi, December I978). WHO­ of the concept of a comprehensive, inte­ sponsored symposia were conducted on grated programme for chronic noncom­ health education in diabetes (Geneva, I979) municable diseases as opposed to the and health care delivery for diabetics in traditional specialty-oriented approach. developing countries (Dubrovnik, Yugo­ One of the points in favour of the inte­ slavia, I979)· In the South-East Asia grated approach is the presence of a group Region, a postgraduate workshop course of risk factors, common to many chronic on diabetes was held in Bangladesh, and diseases, which can be defined as "life also a course for paramedical personnel style" risks. The mobilization of com­ engaged in diabetes care (January I978). munity action requires a new strategy for combating these diseases, and calls for I0.64 The current stage of the WHO corresponding organizational changes. multinational study of vascular disease in diabetics, in which I4 research centres Io.6I Consultations organized during from I 3 countries are collaborating (three the biennium by headquarters and the in the Region of the Americas, one in Regional Office for Europe, and preliminary South-East Asia, eight in Europe, and discussions with national authorities and two in the Western Pacific), was com­ 1 2 3 4 nongovernmental organizations, strongly pleted, • • • and the pattern of further supported the integrated approach and led collaboration was designed at a meeting to initiation of the development of a in Berne (September I979). comprehensive medium-term programme Io.65 WHO collaborating centres con­ for chronic disease control. WHO can tinued their activities in the following utilize the experience accumulated in several areas : (a) research in the pathomorpho­ of its programmes in designing this pro­ logical classification of chronic nonspecific gramme; and certain projects still in lung disease (Leningrad) ; (b) reference and operation have been reoriented in such research in the study of diffuse connective a way that the results can be incorporated tissue diseases (Paris) ; (c) pathomorpho­ into the future development of that design. logical classification of rheumatoid arthritis and related conditions (Mainz, Federal Io.6z The WHO Expert Committee on Republic of Germany) ; (d) histological Diabetes, which met in September/October classification of renal diseases (New York). I 979 in Geneva, drew particular attention in its report to the need for involving the Io.66 The first part of a study on community as well as the patient. It chronic nonspecific respiratory diseases was repeatedly stressed that the main health services for the diabetic should be at com­ 1 Report of the WHO multinational study on vascular munity level, and that preventive, pro­ diseases in diabetics, 1979 (WHO document NCD/OND 79·4). motive, curative, educational and research s Jarrett, R. J. et a!. The WHO multinational study activities should all have their basis in of vascular disease in diabetics : General description, primary health care. 1979· Diabetes care, 2 (2) : 175-186 (1979). 3 Keen, H. & Jarrett, R. ]. The WHO multinational study of vascular disease in diabetics : Macrovascular Io.63 Training of health personnel and disease prevalence. Diabetes care, 2 (2): 187-195 dissemination of information to front-line (1979). 4 health workers was promoted. WHO and Jarrett, R. J. & Keen, H. The WHO multinational study of vascular disease in diabetics : Microvascular the International Diabetes Federation joint- disease. Diabetes care, 2 (2) : 196-201 (1979). THE WORK OF WHO, 1978-1979

completed in I979/ as was the comparative Table 10.1 Situation in relation to DMF index point study, coordinated by the Regional Office for Europe, on the long-term effects on Number of Member States Level of dental caries ------health of air pollution, mainly in relation (at 12 years) Developing Econom1- Overall to chronic lung diseases. cally developed

3 DMF teeth or less 49 4 53

Oral health More than 3 DMF teeth 26 23 49 Io.67 Oral disease problems have in­ No data 53 5 58 tensified in nearly all developing countries over the past two years. In sharp contrast, the efforts WHO has been making for some industrialized countries are now several years to promote national preventive experiencing a reduction in at least one of oral health programmes. The increase has the two main oral diseases-dental caries. been so rapid that in a few developing These trends can be clearly established from countries levels are now as high as any in the the WHO global oral data bank, which highly industrialized countries. To reach now includes data on I I 2 Member States. the goal set by WHO would enable the Io.68 For a number of these countries, developing countries to avoid a huge several sets of data are available that have health and economic burden over the next made it possible to define a specific, two decades. For highly industrialized measurable and practical goal for the countries, it would reduce dramatically the year 2000 : it relates to dental caries, and services and manpower that they now is measured as a mean value at I 2 years of devote to the management of dental caries. age of the index labelled DMF, i.e., Moreover, the attainment of this single, decayed + missing + filled teeth per universally applicable goal would bring person. The strategic point on that index with it numerous subsidiary benefits in is three DMF teeth per I2-year-old child, all aspects of the prevention and care of because this is not only the present crude oral disease. In particular, the oral hygiene average in developing countries where measures that accompany anti-caries dental caries is increasing, but also the methods such as the use of fluorides level to which highly industrialized coun­ would be likely to influence the prevalence tries that have national prevention pro­ of periodontal disease. grammes have managed to reduce the ro.7I Although it may be further disease. refined and modified, the goal is likely to Io.69 The present situation of Member form the basis of oral health programmes States in relation to that index point, as throughout the world. It has already been indicated by the WHO global data bank, largely accepted by the dental profession, is shown in Table Io.r. to which it was proposed by WHO in the course of collaboration with the Inter­ ro. 70 Dental caries is increasing in national Dental Federation. Another· by­ virtually all developing countries, despite product of the emphasis on prevention in WHO's oral health programme is a proposal 1 Heard, B. E. et al. The morphology of emphysema, emanating from a meeting of national chief chronic bronchitis and bronchiectasis : definition dental officers at the Federation's World nomenclature and classification. Journal of clinical pathology, 32: 882-892 (1979). Dental Congress (Paris, I979) that the I98os NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL

should be designated as the decade of a strong extramural component) for prevention for oral diseases. methods of delivery of services, prevention, manpower and epidemiology, was trans­ I0.72 Collaboration with the Inter­ lated into specific plans. At the end of I979 national Dental Federation was signifi­ the first such centre, in Thailand, was near cantly intensified during the biennium. completion. Useful material for these Four joint working groups were estab­ centres should emerge from the inter­ lished, with specific, measurable goals. national collaborative study of dental Three of the groups are directed towards manpower systems, in which I I countries improving methodology in public health have by now participated. spheres ; the fourth deals with educational objectives and curriculum guides for all levels of dental manpower. Radiation medicine I0.73 Within this major reorientation of the oral health programme, the basic I0.77 During I978-I979, the work of activities reported in I977 were continued this programme was oriented towards in all regions. In particular, the integrated better population coverage by radiodiag­ planning of oral health services was the nostic, radiotherapy, nuclear medicine and basis of technical cooperation in I 6 coun­ radiation protection services ; and towards tries, prevention being the top priority in the improvement of methods for quality every case. Field demonstration of pre­ control and for investigating the efficacy ventive programmes continued and will be of widely used procedures. evaluated at the end of a three-year period. In I978-I979, WHO collaborated with Radiodiagnosis 2 5 countries on the epidemiological aspects of oral diseases. I o. 78 World population coverage by radiodiagnostic services presents great dis­ I0.74 Practical manuals were completed crepancies : a few fortunate countries have on integrated planning of oral health one X-ray machine per 2ooo-5ooo popu­ services ; and in the epidemiology pro­ lation, but the great majority of developing gramme a Guide to the Epidemiology and countries have one machine per I ooo ooo Diagnosis of Oral Mucosal Diseases and -even 3 ooo coo-population. The ratios Conditions and a Guide to Oral Health for radiodiagnosticians are even worse. Epidemiological Investigations were prepared. As a result, the number of X-ray examina­ tions per 1000 population varies from more I0.75 Annual coordination meetings than 10oo to less than Io a year. were held, financed by extrabudgetary funds, to identify overlapping and gaps 10.79 At least three levels of radio­ in research needs. Such meetings resulted diagnostic services are required : (I) basic in a comprehensive approach to further services at first referral level; (2) general­ research into the metabolism and use of purpose services at second referral level ; fluorides, and an intensification of work on and (3) specialized services at the level of the monitoring and management of peri­ the specialized hospital, clinical research odontal diseases. institute, university or teaching hospital, etc.

Io.76 The concept of developing, in Io.8o Of these, the first are completely several regions, demonstration centres (with lacking or very scarce in most of the

I47 THE WORK OF WHO, 1978--1979 developing countries. The concept of machines available to different populations : basic radiological services now being pro­ 30% of the world's population has one moted by WHO aims at strengthening machine for more than 20 million people, diagnostic ability at first referral level (thus and only I 7 % has one machine for less reinforcing the primary health care services) than a million people. Approximately 5o% and includes a specially designed X-ray of cancer patients need radiotherapy at machine, along with a training "package" some stage of their disease, so the extent for machine operators and for those inter­ to which such patients are diagnosed and preting the films. The machine is designed treated in a given community has a direct for use in places without electrical power effect on the availability of radiotherapy supply, is easy to maintain, and produces machines in that community. Moreover, consistently good radiographs in the hands utilization of radiotherapy machines is far of a locally recruited operator after a short from optimal. The subject was discussed period of training. During the biennium by a meeting of investigators (Cambridge, technical specifications for such an X-ray United Kingdom, I978), which recom­ machine were prepared and discussed with mended ways of improving the situation, manufacturers ; the training package for particularly in developing countries.1 machine operators was ready for testing ; Io.84 To improve clinical dosimetry, and arrangements were made for field the IAEA/WHO postal intercomparison trials in Colombia and Yemen. An outline service, based on the use of thermo­ for a teaching file on radiographic diagnosis luminescent dosimeters, was continued for general practitioners is being prepared. and its results followed up. The Regional 10.8 I The field trials of this concept of Office for the Americas reviewed the basic radiological services will be followed results obtained in Latin American coun­ up by evaluation by national health author­ tries ; and the Regional Office for the ities of the suitability of such services. Eastern Mediterranean organized a mission The concept has already been tried out, to all radiotherapy departments where with local adaptations, in Finland, Green­ significant deviations had been recorded land and Scotland. and as a result a number of clinical dosi­ meters were replaced. Io.82 With a view to limiting the excessive use of diagnostic radiology and Io.85 Two of the IAEA/WHO second­ the risks and cost it entails, a meeting on ary standard dosimetry laboratories (Bom­ the efficacy and efficiency of diagnostic bay and Buenos Aires) took part in this application of radiation and radionuclides intercomparison, and the network of these was held in Munich-Neuherberg, Federal laboratories as a whole is increasing its Republic of Germany (December I979), work to improve clinical dosimetry. with the financial support of the Federal Exchange of information between partici­ Republic ; it recommended methods for pants was ensured by a series of circular efficacy/efficiency studies that can be used letters to collaborating centres and other by either developing or economically institutes. developed countries. Nuclear medicine Radiotherapy Io.86 Less than 6o% of Member States have nuclear medicine services at the I o. 8 3 There are also great discrepancies in the number of high-energy radiotherapy 1 WHO Technical Report Series, No. 644, 1980. NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL central level of the health care system, and Radiation protection only a few countries, e.g., Japan, the 10.90 Less than half of WHO's Member United States of America and certain States have radiation protection services countries in Europe, can provide adequate that adequately cover the medical use of population coverage. If simplified equip­ ionizing radiation. To improve this situa­ ment and procedures were introduced and tion, WHO continued to provide some radioimmunoassay techniques were devel­ oped more rapidly, nuclear medicine could I 300 film badges a month to a number of countries. These badges are offered free play an important part in such programr;nes of charge by the Service central de Pro­ as the Expanded Programme on Immuruza­ tion and the Special Programme for Re­ tection contre les Rayonnements ionisants, France, and the Institute for Radiation search and Training in Tropical Diseases. Protection and Environmental Research, Federal Republic of Germany. Io.87 Activities in this field were devel­ oped in close collaboration with IAEA. 10.9I Two short courses, intended to They included the preparation of a manu~l increase the self-reliance of countries as on the organization of basic nuclear medt­ regards radiation protection, were organ­ cine services and routine clinical radio­ ized in the Western Pacific Region (No­ isotope procedures, based on material from vember I978 and I979) with the financial the Nuclear Medicine Department, Bombay, support of DANIDA. India; collaboration in a training course and study tour on nuclear medicine, 10.9z A meeting reviewed biological organized in September/December I 979 indicators of radiation effects in man by IAEA and the Government of the USSR (Munich-Neuherberg, Federal Republic of and attended by 33 participants from Germany, December I979), in view of the developing countries ; and preparations growing number of areas where there is for a consultation early in I98o to consider exposure to ionizing radiation, particularly the possibility of using radioimmunoassay in medicine and in nuclear power pro­ techniques in the Expanded Programme on duction. Immunization. Human genetics Io.88 Two workshops on quality con­ trol of nuclear medicine procedures were I0.93 Medical genetics should not con­ held, one in Montevideo (November I979) fine itself to the study of diseases whose and the other in Bombay (December I979)· mode of inheritance is relatively simple : They were organized in conjunction with many more diseases, of considerable public the Regional Offices for the Americas and health significance, need to be analysed for South-East Asia respectively, and with from the genetic point of view. The the Bureau of Radiological Health, Rock­ following are some of the projects in com­ ville, MD, United States of America, a municable and noncommunicable diseases WHO collaborating centre. carried out with WHO support in I978-I979· Io.89 The meeting at Munich-Neuher­ berg, referred to in paragraph Io.8z above, Genetic markers also outlined practical procedures for nuclear medicine and reviewed current 10.94 In five regions of Bulgaria more studies. than 3ooo persons were tested for human

I49 THE WORK OF WHO, 197~1979

leukocyte antigens, red cell antigens, glu­ Management of genetic disorders cose-6-phosphate dehydrogenase (G6PD) deficiency, and haemoglobinopathies. The 10.99 Management of genecic disorders data on human leukocyte antigens sug­ includes treatment of patients with heredi­ gested that the increased frequency of B 5 tary diseases (including establishment of and Bw3 5 was the result of past resistance special diets), genetic counselling combined to malaria in the carriers of those antigens. with detection of heterozygote carriers, The incidence of G6PD deficiency was and screening for certain genetic disorders. found to be lower in populations living at heights of 1000 metres or more ; the pro­ IO.Ioo In a study at the Institute of portion of G6PD-deficient individuals in Zoology, University of Ferrara (Italy) the two lowland areas surveyed was 3·57% a group of 613 heterozygotes for ~-thalas­ and 3·45% respectively, whereas in the saemia-267 married and 346 unmarried­ higher areas it was 1.08%. who had been screened at school age, were interviewed at the average age of 23 to 10.95 In India, 124 persons, in a popu­ assess their knowledge of the heterozygous lation from three villages, were tested for state and its implications. Of those inter­ ABO, MNSs, Rhesus, Kell and Lutheran viewed, 8 3 % recalled some information factors. Most of the affected subjects about their heterozygous state ; Go% had showed Plasmodium vivax infection; only some knowledge of what it meant to be a few were P. Jalcipamm positive. heterozygous, and only 26% were aware 10.96 Studies were carried out to estab­ of any relation between Cooley's anaemia lish the frequency of certain genetic mar­ and the heterozygous state for ~-thalas­ kers, espe.cially human leukocyte antigens, saemia. It was also observed that the both in a normal population and in a series proportion of those who had married of individuals with different diseases. In a another carrier was in line with random study carried out by the Haematology mating expectations. The conclusion was Centre, Bucharest, 534 healthy blood donors that considerable improvement is required were selected for investigation, together in prospective genetic counselling of the with a group of patients with various population in this area. conditions, including 2 5 with ankylosing spondylitis, 6 with Beh<;et's syndrome, 6 with Diihring-Brocq disease, and 10 Registry of chromosomal diseases with disseminated lupus erythematosus. 10.101 The International Registry for The highest frequence found was for the Abnormal Karyotypes, established with HLA-A2 antigen (44 %). The most WHO assistance in the Johns Hopkins frequent combinations of haplotypes were University, Baltimore, MD (United States found for antigens 1-8, 2-13, and 3-7. of America) continued its typological work. 10.97 In a study on silicosis made by Two more listings in the Repository of the Institute of Medical Genetics, Moscow, Chromosomal Variants and Anomalies in the HLA-Bu antigen was the most Man were published, 1 bringing the number frequent among persons with this disease. of listings to six. 10.98 Work continued at the Pasteur Institute, Dakar, on the screening of 1 Repository of chromosomal variants and anomalies in individuals with different haemoglobino­ man. Fifth listing, November 1978 ; Sixth listing, November 1979· Baltimore, MD, Johns Hopkins pathies, especially ~-thalassaemia. University. NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL

WHO collaborating centres and the United States of America. The centre also accepts students from develop­ IO.I02 Support to the following WHO ing countries for long-term training, help­ collaborating centres was continued : ing them to prepare their own research University College Hospital, Ibadan, Nige­ programmes and assisting them in the ria (glucose-6-phosphate dehydrogenase); initial phases after they return to their Population Genetics Laboratory, Univer­ home institution. In I979 such assistance sity of Hawaii, Honolulu, United States of was given to the Oswaldo Cruz Foundation, America (processing of human genetics Rio de Janeiro, and the University Centre data) ; and the Institute of Genetics and for Health Sciences, Yaounde. WHO Biophysics, Naples, Italy (glucose-6-phos­ cooperated for the second time in a course phate dehydrogenase). in basic immunology at the Girls' College, Al Azhar University, Cairo. Immunology I o. 106 The collaborating centre for research on the immunopathology of Io.Io; During the biennium WHO dengue haemorrhagic fever, Bangkok, co­ immunology research and training centres ordinated research on dengue vaccine for were in operation in all regions. However, use in the South-East Asia and Western at the end of I978 the centre in Nairobi Pacific Regions. was transferred to the University, its training and research work continuing I o. I 07 Allergies are of public health under the direction of national staff. concern in many countries. A meeting was A request was received from the Brazilian held in July I978 to assess the extent and Government for a collaborating centre in gravity of allergic disorders in both the immunology of parasitic and mycotic developed and developing countries ; its diseases to be established at the Oswaldo report contained recommendations on the Cruz Foundation, Rio de Janeiro. part WHO should play. I o. I 04 Training was carried out in the research and training centres in Amsterdam, Io.I08 A meeting on immunological Rehovot (Israel), and Sao Paulo (Brazil). recognition and effector mechanisms in The Rehovot centre organized a two-week infectious diseases was organized in I979· course on molecular and cellular aspects It reviewed the present state of knowledge of antigenicity that was attended by 20 on the subject and made recommendations participants from all regions; while the for research to improve the immuno­ Amsterdam centre was instrumental in genicity of substances produced from establishing laboratories for clinical immu­ infectious organisms and used in vaccine nology in Cuba, Jamaica and Suriname, production. with financial support from the Govern­ ment of the Netherlands. I o. I 09 In collaboration with the Inter­ national Union of Immunological Societies, IO.I05 Regular courses on the immu­ international standards were prepared and nology of infectious diseases were held at accepted for fluorescein-labelled anti-human the centre in Lausanne/Geneva (Switzer­ IgM, and for serum proteins. The first of land) in both French and English, sup­ these standards is held at WHO head­ ported financially by the Swiss Govern­ quarters for distribution to research ment and with the assistance of Belgium workers.

rp THE WORK OF WHO, 1978--1979

I o. I I o A loose-leaf booklet of labo­ tion (Special Programme of Research, ratory techniques in clinical immunology Development and Research Training in (replacing an earlier booklet) was prepared Human Reproduction), in the work of its and widely distributed. It will be brought steering committee, and in the scientific up to date periodically. working groups and steering committees of the Special Programme for Research I o. I I I A programme for the pro­ and Training in Tropical Diseases. They duction of immunological reagents used worked in conjunction with the latter in the diagnosis of diseases of public programme in running courses in Lausanne health importance has been started. A (Switzerland) and Belo Horizonte (Brazil) course on the subject for participants from on the in vitro production of monoclonal the Eastern Mediterranean was organized antibodies by the new technique of cell in Islamabad. hybridization ; in organizing a meeting on the role of the spleen in the immunology I o. I I 2. Staff of the immunology pro­ of parasitic diseases ; and in evaluating the gramme took part in the task force on institutions considered in connexion with immunological methods of fertility regula- the institution-strengthening programme. Chapter II

Promotion of Environmental Health

Programme development implementation of national programmes. The emphasis on these aims has led to the II. I IN I979 a medium-term programme elaboration of programmes concerned with for the promotion of environ­ the International Drinking-Water Supply mental health covering the six­ and Sanitation Decade, I98I-I990 (resolu­ year period I978-I983 was endorsed by tion WHA30.33) and with chemical safety the Thirty-second World Health Assembly (resolutions WHA30.47 and WHA31.28). (resolution WHA32·3 I). It took into account the new concept of primary health care, I 1.3 The Organization cooperated with stressing multidisciplinary and intersectoral Member States in the planning and re­ action, the priority given to planning and inforcement of programmes and services programming, and the role of WHO as for environmental health within various regards resources outside the country national administrations. Some of the concerned that could contribute to the activities involved were supported with improvement of health. Particular atten­ a view to encouraging the initiative of tion was given to the expressed priorities health agencies and strengthening their and needs of Member States. participation in the planning of environ­ mental health programmes. The resources I 1.2 Two of the major aims of the pro­ needed to cope with environmental health gramme are : (I) technical cooperation in problems usually being limited, they must planning and programming for basic sani­ be used economically and effectively; a tary measures (particularly water supply systematic planning effort is needed. In and sanitation), with the emphasis on rural collaboration with Member States and the and underserved populations, along with regional offices, a guide for national cooperation in strengthening institutional environmental health planning was and managerial capacity and the transfer prepared. of information and experience; and (z) worldwide assessment of the new environ­ I I ·4 The establishment of environ­ mental hazards arising from socioeconomic mental protection agencies in an increasing development programmes and projects now number of countries has created a new under way in all countries-hazards that need for technical cooperation in formulat­ must be prevented if the benefits of develop­ ing policies to meet new types of environ­ ment are to be safeguarded-, along with mental objective. A survey carried out in technical cooperation in the planning and I978 in seven countries (in three regions) THE WORK OF WHO, 1978-1979

showed the importance of establishing demiology in environmental protection ; adequate mechanisms for coordinating administration ; and coordination mechan­ environment and health programmes at isms. It is worth noting that, with WHO various administrative levels. In I979 this cooperation, sanitation services are being study was pursued with the participation developed by the ministries of health of of 2I countries in all six WHO regions. 2 I African countries, and that seven countries have set up ministries for the Institutional development environment as part of national policies that aim at preserving the quality of life I I. 5 In the African Region the main while safeguarding the physical environ­ attention during the biennium was given ment in both urban and rural areas. to the interrelationship of basic sanitation with community organization and develop­ I I .6 In the European Region WHO ment. In I 978 a regional meeting of experts collaborated with institutes of higher educa­ advised on the role of basic sanitary tion in the fields of environmental science measures in community organization in and human ecology. It compiled a directory rural areas. It highlighted the multi­ of training courses in the environmental disciplinary nature of environmental health field, carried out a survey of environmental action and the complementary role played services, and conducted studies of man­ by different community development sec­ power development including "profiles" tors. Regional workshops were convened for different professions. As an outgrowth within the programme of technical cooper­ of these studies, a document containing ation among developing countries to guidelines on manpower planning in discuss the development of simple tech­ environmental health was prepared in I 978 niques for the construction and installation and distributed to all Member States in the of sanitation equipment and the diffusion Region as a planning aid in establishing of technical information among countries the types and number of personnel required of the Region. A regional network of by environmental health services, whose environmental health centres now being needs often differ widely from country to set up will utilize national expertise to the country. With WHO cooperation, the largest possible extent and, it is hoped, Government of Greece decided to establish reinforce this programme. An intercountry an environmental institute that will address project was established to promote close itself to the problem of preserving and cooperation at both regional and sub­ improving the quality of the environment regional level and the possible integration in parts of Greece other than Athens, where of sanitation and primary health care a UNDP-assisted project on environmental activities, and to reinforce intersectoral pollution control has entered its final stages. coordination. With the technical collabora­ The Turkish Government is also making tion and financial assistance of DANIDA, plans, with WHO participation, to set up an interregional workshop on environment a central organization for environmental and development was held in the French protection. language at Libreville in I979· This workshop, like its English language I I. 7 In the Eastern Mediterranean counterpart held a year earlier in New Region WHO cooperated with the Govern­ Delhi, reviewed environmental health fac­ ment of Iraq, which has undertaken a tors in national health planning and in complete reorganization of the human development projects ; the use of epi- environment directorate within its Ministry

I 54 PROMOTION OF ENVIRONMENTAL HEALTH

of Health and considers this action as being rural water supply, drinking-water criteria crucial to its long-term plans for investment and standards, and assessment of environ­ in the health sector. Cooperation along mental impact. Institutional development these lines was also provided for solid in the Philippines progressed with the wastes disposal in Oman and the United establishment in I978 of a Ministry of Arab Emirates. Air pollution monitoring Human Settlements that supervises various and control were strengthened in Egypt, aspects of the environmental health pro­ Iran, Iraq, Israel, and Pakistan. Health gramme, including air and water pollution institutes training environmental health control, assessment of environmental impact workers were supported in Democratic and environmental planning. As part of Yemen, Jordan, Libyan Arab Jamahiriya, the reorganization, the national pollution Pakistan, Qatar, Saudi Arabia, Sudan, control commission, the national environ­ Tunisia, and Yemen. mental protection council, and the human settlements regulatory commission were I I. 8 Some countries in the Western brought under the umbrella of the Ministry Pacific Region have still not been able of Human Settlements. A regional seminar to give priority and resources to devel­ on environmental health manpower devel­ oping the capacity of their institutions in opment was held in September I978 at the environmental health field, while others Manila and its report was issued in January have created new environmental protection I979· agencies with which WHO has established technical cooperation programmes. Legal International programme on chemical safety and administrative provisions for environ­ mental planning need to be drafted or I I ·9 An international programme on extended to cope with the growing prob­ chemical safety was initiated in I979 on the lems of environmental management. In basis of the specific guidance provided by these matters the Western Pacific Regional the Thirty-first World Health Assembly Centre for Promotion of Environmental (resolution WHA3 1.28) and the Executive Planning and Applied Studies is assuming Board at its sixty-third session (resolution an active role. The Centre was established EB63.RI9). The programme is a stepping in I978 by WHO in Kuala Lumpur in up of the Organization's existing pro­ collaboration with the Government of grammes on chemical safety and entails Malaysia. Also in Malaysia, WHO coop­ the cooperative efforts of a network of erative services in the provision of rural national institutions and a WHO central water supply facilities were reinforced by unit supported by extrabudgetary con­ the establishment of an environmental tributions. The principal objectives of the health and engineering unit within the programme are: (I) to carry out and Ministry of Health. In Papua New Guinea, disseminate evaluations of the effects of the development of an environmental chemicals on human health and the environ­ health programme was slow in the initial ment; (z) to develop guidelines on exposure stages but is progressing now that counter­ limits; (3) to develop guidelines on appro­ part staff returned from overseas training priate methods for toxicity testing, epi­ have been assigned to it. In the Philippines, demiological and clinical studies, and risk consultant services were provided in several and hazard evaluations ; (4) to coordinate areas of environmental health, including laboratory testing and epidemiological air and water pollution control, manpower studies where an international approach development, solid wastes management, is appropriate, and to promote research ;

155 THE WORK OF WHO, 1978-1979

(5) to provide information on coping with Coordination chemical accidents and promote effective I I. I 2 The implementation of the international cooperation in the control environmental health promotion pro­ of toxic substances· in Member States, and gramme requires coordination, both internal ( 6) to promote the training and develop­ and external, to ensure (a) that it makes ment of manpower. a full contribution to health, and (b) that programmes with environmental aspects I 1. I o In I 979 details were negotiated are compatible with the health policies with I o Member States for the designation of national institutions and for financial and objectives of Member States. Besides arrangements with the United Nations contributions to the programme. A WHO central unit was established, and a pro­ itself, UNDP, UNICEF, ILO and FAO, and with the World Bank for cooperative gramme advisory committee was formed. action in water supply and sanitation (see The International Agency for Research on Cancer agreed to assume the role of paragraphs I 1.25-I 1.27 below), special coordination mechanisms were developed leading institution for chemical carcino­ genesis. Other international organizations with UNEP and IAEA. agreed to collaborate and, in some cases, I I. I 3 Coordination within WHO was to cosponsor the programme; they include strengthened in the regions and at the UNEP, ILO, and FAO. centre to ensure linkage of this programme with those in other areas, e.g., primary I I. I I A consultation on manpower health care, water-related diseases, certain development in toxicology was convened noncommunicable diseases, and health man­ by the Regional Office for Europe (Decem­ power development. ber I978).1 A project was started on European cooperation in the environmental health aspects of the control of chemicals, Provision of basic sanitary measures intended for those countries in the Region that are eligible for support from UNDP. Preparation for the International Drinking- It will form a regional component of the Water Supp!J and Sanitation Decade international programme on chemical safety in such areas as manpower development, 1 I. 14 During the biennium there was contingency planning, rapid response in a realignment of the Organization's activi­ emergencies, and technical cooperation on ties in basic sanitation : the provision of specific matters. The Regional Office for basic sanitary measures is now viewed in the Americas also initiated a number of the light of the International Drinking­ activities, particularly in technical coopera­ Water Supply and Sanitation Decade,I98I­ tion and manpower development. They I99o, as designated by the United Nations were carried out through the Pan American Water Conference (Mar del Plata, Argentina, Center for Human Ecology and Health 1977). The Thirtieth World Health in Mexico City and the Pan American Assembly (I977) had urged Member States Center for Sanitary Engineering and to undertake as a matter of urgency the Environmental Services in Lima. assessment of their water supply and sani­ tation sector and to elaborate measures through which national programmes could 1 World Health Organization. Manpower development be adjusted to the goals of the Decade in toxicology. Report on a WHO Consultation. Copenhagen, 1979 (EURO Reports and Studies, No. 9). (resolution WHA3o. 33). PROMOTION OF ENVIRONMENTAL HEALTH

I I . I 5 The task of assessment was carried particularly the shortage of manpower for out with the cooperation of WHO and the formulating plans and projects. World Bank. It entailed a country-by­ country review to evaluate on the basis I I. I 8 Commitments by governments of such information as was readily available to increased allocation of resources to (a) the preparedness of countries to accel­ water supply and sanitation are needed to erate the development of basic sanitation ; encourage greater international participa­ (b) the action required in formulating tion. International cooperation during the national plans for the Decade during the preparatory phase is required most of all preparatory phase (I978-I98o); and (c) the in the elaboration of plans, the formulation need for international cooperation in pre­ of projects, and manpower development. paring development plans for the Decade. The state of preparedness varies from region to region : the Latin American countries I I. I 6 Governments responded posi­ are the best prepared, since at Punta del tively and in I 978 rapid assessments were Este, Uruguay (I96o) and Santiago, Chile carried out in I04 countries. Different (I97o) specific goals had been set for the methods were adopted in the different I96os and I97os. African countries south WHO regions. The African Region used of the Sahara are those where the need to a training approach, with national rep­ develop plans and programmes is greatest. resentatives attending workshops in Ouaga­ dougou and Nairobi. This had the advan­ I I. I 9 Consultations took place between tage of ensuring the active participation the organizations most directly concerned of officials responsible for national pro­ within the United Nations system (the grammes and a relative uniformity of United Nations itself, UNDP, UNICEF, approach. In the Region of the Americas, ILO, FAO, WHO and the World Bank) on the other hand, national activities were with the aim of improving coordination supported in individual countries. For the within countries and establishing regular assessments in other regions, national consultations among the governments, experts, field, regional office and head­ intergovernmental organizations, and non­ quarters staff (including staff of the World governmental organizations involved. As Bank(WHO cooperative programme), and a result the UNDP resident representatives consultants were relied upon. Some assumed a key role in the coordination of governments have already made use of the contributions by agencies in the United assessments as a basis for the expansion Nations system. The mechanisms evolved of their national plans and programmes and should also encourage bilateral and other for negotiations with potential donors. development aid agencies to cooperate with governments in respect of the Decade. I I. I 7 The assessment showed that few The resident representatives are supported countries have as yet taken the step of technically by WHO and the other collab­ translating the general goals of the Decade orating agencies through their regional and into specific national programmes of action. country-level staff. The reordering of priorities and the redeployment of resources must in many I 1. zo A steering committee was formed, cases await a new five-year or similar plan. consisting of the agencies of the United The assessment also confirmed the existence Nations system concerned, to review and of constraints on the progress detailed in develop policy, create a coordinated the United Nations Water Conference, approach to the management of individual THE WORK OF WHO, 1978-1979 programmes, and prepare for consultative I 1.23 In the African Region UNICEF meetings with representatives of govern­ and WHO continued their collaboration ments in a position to offer technical and within countries in the integration of financial cooperation. WHO provides the environmental sanitation and water supply secretariat for the steering committee. programmes within the framework of primary health care. Preinvestment studies, I I.Z I Consultative and other meetings earlier financed by UNDP, are being pro­ were arranged with representatives of gressively taken over by the national governments and funding institutions. authorities, their integration within the WHO collected information from the national services leading to new forms of developing countries on progress, con­ technical cooperation. The Regional Office straints and needs, and from official develop­ for the Americas placed special emphasis ment aid agencies and other funding on collaboration with governments in the institutions on their criteria, policies, and operation and maintenance of drinking­ procedures. At the first consultative water systems and the training of water­ meeting of official development aid agencies, works personnel. Attention was also given funding institutions, and collaborating to the increasing problems countries are agencies (Geneva, I978) WHO was facing in the management of solid wastes. requested to examine the possibility of The Regional Office for South-East Asia instituting a system for gathering informa­ assigned sanitary engineers to almost all tion on projects in developing countries the countries in the Region. It cooperated that could be supported by multilateral or in the establishment of national committees bilateral donors. for the Decade, and held a regional con­ sultation of national and international agency staff to discuss strategies and follow­ Technical cooperation at national/eve/ up action. The intercountry programme in Europe was particularly concerned with I Lzz An effort was made to intensify environmental health problems in tourist the involvement of other international areas and the impact of fluctuating popula­ agencies at national level. WHO's long­ tions. Most of the water supply and wastes standing collaboration with UNICEF in disposal projects in countries included a national water supply and sanitation pro­ strong training component. In the Eastern grammes was maintained and strengthened. Mediterranean Region WHO intensified In I978 the UNICEF/WHO Joint Com­ its support for solid wastes management mittee on Health Policy reviewed a report in several countries, notably Mghanistan, on water supply and sanitation components Oman, Sudan, and Yemen. A regional of primary health care - a joint report seminar emphasized the need for countries based on six extensive case studies from to adopt appropriate low-cost technology Bangladesh, Columbia, Ghana, India in sanitation programmes. The Western Nepal, and the Philippines. The main Pacific Region aimed at developing in­ issues were water supply and sanitation creased institutional capacity to plan and policy, community participation, the insti­ implement projects, and helping countries tutional infrastructure, education, per­ to establish a dynamic planning process. sonnel, technology, and maintenance. The conclusions of this study were presented I 1.24 In late I978 extrabudgetary funds to the Executive Boards of UNICEF and from the Federal Republic of Germany, WHO in I979· SIDA, and UNDP became available for PROMOTION OF ENVIRONMENTAL HEALTH planning for the International Drinking­ II.27 The cooperative programme is Water Supply and Sanitation Decade in moving towards greater integration with 37 countries. Such planning included the intersectoral activities, as part either of identification of projects suitable for external primary health care or of wider urban and investment and measures to lessen or rural development schemes focusing on remove the constraints on development in the reduction of poverty. the sector. Technological development I 1.28 Member States were given World BankfWHO cooperative programme support in starting information systems on technology. In this connexion, the I 1. 2 5 In I 97 8 most of the effort went Netherlands Government provided funds into the assessments in countries referred for a programme on the exchange and to in paragraphs I 1. I4-I 1. I 8 above. Other transfer of information that is being more specific studies, for instance on implemented by the international reference national water supply tariff structures and centre for community water supply (Voor­ on manpower development, were under­ burg, Netherlands). WHO collaborating taken in I 2 countries, mostly in Africa. centres published regular newsletters docu­ Ad hoc planning support was given to menting technological progress. The countries in preparation for the Inter­ newsletter on water supply now reaches national Drinking-Water Supply and Sani­ about 24 ooo subscribers. tation Decade, and a national conference I 1.29 was organized in Turkey in I 97 8 to establish Attention was given to new a suitable strategy. Preparatory work along technological developments in, for example, similar lines was supported in Algeria, solar power for water supplies, methods Portugal, and Somalia. of rainwater collection, and wastewater re-use. Support was provided for studies on, or for the technological development I 1.26 In the use of cooperative pro­ of, handpumps (testing and evaluation), gramme resources, an increasing share slow sand filtration, disinfection of water, went to the least developed countries, standardization of equipment and materials, mostly situated in the African Region. simplified methods of water examination, A regional manpower development and rural excreta disposal facilities, the evalua­ training survey covering most countries tion of aqua-privy and smallbore sewer in West Africa drew attention to the man­ systems, and guidelines on the health power situation in the water and sanitation aspects of water desalination. Other studies sector and led to an exploration of local that received support concerned water and regional strategies for meeting man­ supply through public standposts, the power needs within the context of the removal of excess fluorides, the health Decade. National seminars on planning aspects of plumbing, the technology of and project preparation were held for waste stabilization ponds, and the treatment sector agency managers from the different of small-scale water supplies. states in Nigeria and India. A workshop dealing specifically with the economic and I I. 30 The promotion of drinking-water financial aspects and with alternative low­ quality surveillance as part of community cost technologies was organized in the water supply development received further African Region for both WHO staff and emphasis in global and regional environ­ national participants. mental health programmes. Particular stress THE WORK OF WHO, 1978-1979 was placed on establishing or strength­ volumes. This programme is carried out ening the institutional infrastructure in in collaboration with some 2 5 Member the developing countries and on the role States and UNEP ; it receives the strong of health agencies in the community water support of several collaborating centres supply and sanitation sector. The Regional and of the International Radiation Pro­ Office for the Americas paid increased tection Association (ultraviolet, microwave, attention to the special needs of rural and and other nonionizing radiations). peri-urban areas. The South-East Asia Region included a drinking-water quality I 1. 3 2 To assist in the preparation and surveillance programme in its regional use of the criteria documents, a volume was medium-term environmental health pro­ prepared for that series that discusses the gramme. The Regional Office for the terminology used in evaluating the effects Eastern Mediterranean provided consultant on health of environmental agents and services on water quality control to certain assessing the risks and hazards. countries. In the Western Pacific Region I I. 33 Further steps were taken to arrangements were made to organize facilitate the use of environmental health regional courses on drinking-water quality criteria in formulating national environ­ surveillance in the South Pacific. The mental health standards and other action prevention of risks to health through to improve the human environment. A continuous and systematic surveillance of guide to principles and procedures for drinking-water quality was selected as an establishing environmental health stan­ important joint UNEP /WHO activity for dards is in preparation. the Decade and was included in a number of cooperative projects funded by bilateral I 1.34 International Standards for Drink­ agencies and UNDP. ing-7vater and European Standards for Drink­ ing-water were last revised and published Control of environmental pollution and in I97I and I97o respectively. In I978 hazards the European Regional Office and head­ quarters began to revise and merge them II.3I In I979 the WHO environmental into one edition, and a consultation to lay health criteria programme was in its sixth down the framework for the revision was year of operation. During the biennium held (Copenhagen, December I978). eight criteria documents dealing with During the biennium working groups were different environmental agents were pub­ convened by the Regional Office for Europe lished, 1 bringing the total number already on the significance for health of various 1 2 3 published under the programme to I2. aspects of drinking-water. • ' A meeting Work is well advanced on another 15 1 World Health Organization. Sodium, chlorides, and conductivity in drinking-water. Report on a WHO working 1 World Health Organization. Nitrates, nitrites and group. Copenhagen, 1979 (EURO Reports and Studies, N-nitroso compounds. Geneva, 1978 (Environmental No.2.). Health Criteria, ~); Photochemical oxidants. Geneva, 2 1978 (Environmental Health Criteria, 7); Sulfur oxides World Health Organization. Health effects of the and suspended particulate matter. Geneva, 1979 (Environ­ removal of substances occurring naturally in drinking-water, mental Health Criteria, 8); DDT and its derivatives. with special reference to demineralized and desalinated water. Geneva, 1979 (Environmental Health Criteria, 9); Report on a WHO working group. Copenhagen, 1979 Carbon disulfide. Geneva ,1979 (Environmental Health (EURO Reports and Studies, No. 16). Criteria, ro); Mycotoxins. Geneva, 1979 (Environmental 3 World Health Organization. Radiological examination Health Criteria, rr); Carbon monoxide. Geneva, 1979 of drinking-water. Report on a WHO working group. (Environmental Health Criteria, r 3) ; Ultraviolet radia­ Copenhagen, 1979· (EURO Reports and Studies, tion. Geneva, 1979 (Environmental Health Criteria, q). No. 17).

I6o PROMOTION OF ENVIRONMENTAL HEALTH on the microbiological quality of drinking­ light of the new recommendations of the water was held in I 979, and will be followed International Commission on Radiological by a series of other meetings. This project is Protection. A joint IAEAJILO JWHO supported financially by DANIDA and by seminar on this subject was convened in the WHO collaborating centre on environ­ I979· WHO continued to cosponsor the mental pollution control at the United publication of selected monographs in the States Environmental Protection Agency. IAEA Safety Series. Arrangements for Among the WHO collaborating centres mutual emergency assistance for radiation participating actively in the revision of accidents were reviewed jointly by drinking-water standards are the Water UNDRO, ILO, FAO, WHO, and IAEA. Research Centre, Medmenham, United The Regional Office for Europe convened Kingdom, and the Environmental Health a working group in I 979 to consider the Directorate, Health Protection Branch, health consequences of new developments Department of National Health and Welfare, in nuclear power production ·and in other Ottawa, Canada. peaceful uses of the nuclear industry. Cooperation with UNSCEAR was con­ I I. 3 5 The promotion of appropriate tinued, particularly jn relation to the evalu­ methods for evaluating environmental risks ation nf the effects of environmental radio­ remains an important objective. In I978 activity. the first part of a volume on principles and methods for evaluating the toxicity of I 1. 38 Environmental health monitor­ chemicals was published. 1 The second ing is an important part of WHO's pro­ part is in preparation. In I979 a companion gramme in the control of environmental work on epidemiological methods for pollution and hazards. Under the air quality environmental health studies was started monitoring project, which is supported in collaboration with the International by UNEP, monitoring stations were estab­ Epidemiological Association. lished in I 5 major cities with no previous I 1.36 In addition to evaluation of the monitoring capability and were strength­ health risks associated with exposure to ened in others. In all, the air quality individual environmental agents or com­ monitoring project now includes I70 moni­ binations of environmental agents, the toring stations in 46 countries and incor­ environmental health aspects of entire porates a number of stations from the Pan industrial sectors were examined. In I978 American air sampling network. Work­ reviews were carried out of the manufacture shops or training courses were held in and use of synthetic organic chemicals Bangkok, Lima, Nairobi, and Sofi~. As and of the iron and steel industry. In I979 regards water quality monitoring, which is a similar review was undertaken of the also supported by UNEP, a network of production and use of nonferrous alloys. approximately 330 stations in nearly 70 These reviews provided an environmental Member States was established and water health component in UNEP's industry and quality data are beginning to be collected environment programme. and analysed. An operational guide was issued in I978. Training courses were held I I. 37 Basic safety standards for radia­ in Alexandria, Lima, Manila, and Nagpur tion protection are being reviewed in the (India) and a pilot course on analytical quality control was held in Mexico. The 1 World Health Organization. Principles and methods for evaluating the toxicity of chemicals, Part I. Geneva, WHO collaborating centre for surface and 1978 (Environmental Health Criteria, 6). · ground water quality at the Canada Centre

161 THE WORK OF WHO, 1978-1979 for Inland Waters, Burlington, Ontario, the Laguna de Bay comprehensive water is serving as the data centre for this project. quality project in the Philippines was followed up, and air and water pollution I 1. 39 The environmental radiation control advisory services were provided monitoring programme, implemented by to governments. In the Region of the the WHO collaborating centre at the Central Americas, Member States were assisted by Service for Protection against Ionizing the Pan American Center for Human Radiation, Le Vesinet (France), together Ecology and Health and the Pan American with some 30 national laboratories in Center for Sanitary Engineering and En­ 2 I Member States and four WHO collabor­ vironmental Sciences in defining environ­ ating centres, has been in progress since mental degradation problems associated I972. A cooperative research project was with industrialization and urbanization. A begun on chromosome aberrations ; it is start was made in preparing guides for the being carried out with a number of WHO use of national health officials in making collaborating centres and other national in­ their own assessments of the ecological and stitutions, and aims at developing a method health effects. The questions of indoor air for the biological monitoring of exposure quality of concern in the European Region to both ionizing radiations and chemicals. were considered by a working group, which

I 1.40 Recommended by a joint meeting recommended that guidelines should be of UNEP, WHO, and governmental ex­ produced for indoor air quality and also 1 perts, a pilot project was started to improve guidelines on air quality for use in building methods of assessing the amounts of lead, codes. mercury, cadmium, and selected organo­ I I .42 The planning of adequate national chlorine compounds in human tissue and environmental pollution control pro­ fluids. Thirteen Member States, both grammes must be based inter alia on infor­ developed and developing countries, are mation as to the location and size of sources participating in the project, for which the of pollution ; the limited resources available Department of Environmental Hygiene of to control and prevent environmental the Karolinska Institute, Stockholm, and pollution can then be allocated to solving the Swedish National Food Administration the most pressing problems. WHO began are serving as coordinating institutions. a field programme to evaluate the method­ ology for rapid assessment of air and water I 1.4I Though progress has been noted pollution sources in urban areas in Abidjan, in some countries, in general environmental Bangkok, Bombay, and Jakarta. A guide pollution control programmes need ba~ed on the field experience obtained is developing and strengthening because of now being prepared. To assist with the rapid economic development and urbaniza­ design and planning of adequate national tion. To help countries in this connexion, automobile exhaust control programmes, the Regional Office for South-East Asia a series of interregional workshops is being is preparing a regional programme in planned in cooperation with UNEP. environmental pollution control, and organized a regional seminar on assessment I I ·43 WHO has taken a leading part of the effects of pollution on environmental in developing guidelines and criteria for health. Regional seminars with the same the protection of the coastal waters of the aim were also organized in Czechoslovakia 1 and Greece by the Regional Office for W odd Health Organization. Health aspects related to indoor air quality. Report on a working group. Copen­ Europe. In the Western Pacific Region, hagen, 1979 (EURO Reports and Studies, No. 21). PROMOTION OF ENVIRONMENTAL HEALTH world, which is a major part of the UNEP control of foodborne infections and intoxi­ regional seas programme. In the Mediterra­ cations. A meeting of representatives of nean in particular, WHO, through its European Member States (Geneva, I979) European and Eastern Mediterranean discussed the implementation of the pro­ Regional Offices, coordinates health sur­ gramme, which is to become operational veillance (with standard methods and in I98o. In the Eastern Mediterranean automated data analysis) of selected coastal Region WHO cooperated with various recreation areas and shellfish-growing countries in strengthening food sanitation waters, in collaboration with ECE, UNEP, services and helped to develop programmes F AO and UNESCO. WHO also took to establish effective infrastructures for part in developing and implementing action municipal, provincial, and national action. plans for other parts of the regional seas In the Western Pacific Region, advisory programme, with emphasis on the Kuwait services on food safety were furnished to area and West Africa. In a related pro­ Malaysia, the Philippines, and the Republic gramme, a series of workshops was started of Korea. In I979 a working group on in collaboration with the United Nations, food hygiene and food safety met in Kuala UNIDO, FAO, UNESCO, and IMCO on Lumpur. assessment of the environmental effects I 1.45 The coordination of international of coastal area development and incorpora­ postgraduate training courses in food tion of assessment procedures in national microbiology for students from develop­ planning. ing countries has resulted in the integration of the activities of the four training centres Food safety 1 in Europe participating in this programme. I I ·44 In the African Region coopera­ The trend now is to conduct these courses tion with Member States was directed in developing countries, and a WHO towards reinforcing national structures for intercountry workshop on advanced micro­ food protection. In the Region of the biological methods in food hygiene was Americas new national food protection held in Izatnagar (India) early in I979· programmes were developed in Ecuador, I I .46 The primary objective of the Guatemala, and Peru. Under the regional joint FAO/WHO food standards pro­ education programme for food protection, gramme under the aegis of the Codex based in Columbia, I 76 professional staff Alimentarius Commission, which has a and 45 food inspectors were given a two­ membership of I I7 countries, is to protect year training course. In the South-East consumers from the health hazards related Asia Region food safety activities were to food and also from fraudulent practices. limited to the collection of information on It attempts to do so by establishing inter­ which to base future action. The European national or regional food standards and Region began the preparation of a UNDP­ drawing up codes of practice for the financed project on regional cooperation safe handling of food. During I978-I979 in food safety services, the emphasis being two sessions of the Commission and on mass catering and on food safety I9 commodity and general subject com­ information and regulations. Work was mittee meetings were convened. Meetings also undertaken on the establishment of were held of the coordinating committees a regional surveillance programme for the for Africa, Asia, and Europe. A regional 1 For food safety in relation to veterinary public health, conference for Latin America was also see Chapter 9, paragraphs 9.156-9.159 and 9.162. convened. THE WORK OF WHO, 1978-1979

I 1.47 At its twelfth session (Rome, I 1.49 The Jomt meeting of the FA0 I978) the Commission reviewed and Panel of Experts on Pesticide Residues and assessed the results of its work. It agreed Environment and the WHO Expert Group that the work of its general subject com­ on Pesticide Residues was convened twice mittees (food hygiene, food additives, (I978 1 and I979) to provide toxicological pesticide residues, food labelling, methods evaluations and establish maximum residue of analysis and sampling, and general limits in foods for a large number of principles) was essential to its future pesticides. In addition, two meetings of activities and of value to both developed the Joint FAOfWHO Expert Committee and developing countries. However, it on Food Additives were held (I978 2 and decided that five Codex committees that I979)· At the I978 session specifications had completed their assignments should and acceptable daily intakes were established adjourn sine die. This decision should for a number of food additives. Toxico­ enable the Commission to devote more of logical evaluations or re-evaluations were its time and activity to the needs of develop­ also carried out on the following food ing countries. The Commission also estab­ contaminants: asbestos, lead, mercury, lished new Codex committees for cereals methyl-mercury, inorganic tin salts, and and cereal products and for vegetable organotin compounds. At the I 979 session proteins. At the same session the Codex a number of food colours, solvents, flavour­ Alimentarius Commission gave particular ing substances, and other food additives attention to the role and work of its coor­ were considered. A WHO expert consulta­ dinating committees for Africa, Asia, and tion on paralytic shellfish poisoning (I978) Latin America and assigned to them new recommended ways of strengthening pre­ functions to make them more effective in ventive and control measures at inter­ advancing the interests of their respective national and national level and the pre­ regions. paration of a guide.

I 1.48 At its thirteenth session (I 979) I qo Under the JOlnt FAOfUNEP/ the Commission gave consideration to a WHO food and animal feed contamination code of ethics for international trade in monotoring programme, stage II, guide­ food in addition to examining a large lines for establishing or strengthening number of international food standards national food contamination monitoring and codes of practice for the safe handling programmes and a summary report of data of foods. As part of a long-term pro­ received from collaborating centres for gramme for the development of inter­ food contamination monitoring (stage I, nationally acceptable microbiological cri­ I977) were issued. During I978 data were teria for foods, an FAO/WHO working received from the collaborating centres on group met in I 979 to consider and amend organochlorine pesticides, lead, and cad­ draft texts on general principles for the mium in a variety of foods. In I 979, in establishment of microbiological criteria addition, information was received on the for foods and on criteria for raw meat and total dietary intake of organochlorine poultry. The work carried out jointly with pesticides, lead, cadmium, and aflatoxins. F AO on an international code of principles for antemortem and postmortem judgement 1 FAO Plant Production and Protection Paper of slaughter animals and meat was finalized No. I 5, 1979. by a group of experts in I979· 2 WHO Technical Report Series, No. 6p, 1978. Chapter 12

Health Manpower Development

12. I THE LACK of health manpower Director-General to establish a medium­ is often the principal obstacle term programme that would translate its to the delivery of health care. objectives into a set of relevant activities, The insufficient number of health workers, with definite targets. Such a medium-term their uneven distribution, and only too programme for the years I978-I983 was often the irrelevance of their training are discussed by the regional committees and perennial problems for many countries. in I978 was endorsed by the Thirty-first World Health Assembly (resolution I 2.2 The constitutional role of WHO WHA31.36). in relation to the training of national health personnel was redefined by the Twenty­ I2.4 The Declaration of Alma-Ata ninth World Health Assembly in I976 emphasized that the delivery of primary (resolution WHA29.72) in order to increase health care would require health workers the relevance of the health manpower suitably trained socially and technically to development programme to the require­ work in teams in order better to respond ments of Member States and to promote to the needs of communities. The Inter­ manpower systems that will produce, in national Conference on Primary Health sufficient numbers, health personnel whose Care at which the Declaration was adopted training has been relevant to the health recommended that governments should needs of the population they are to serve. give high priority to the full utilization of The resolution called for cooperation human resources by defining the technical between WHO and Member States in the role, supportive skills, and social attitudes formulation of national health manpower required for each category of worker in the policies and plans, the development of health team ; and should undertake the health teams (especially for the delivery training and reorientation of all categories of primary health care), the institution of of health workers to prepare them for their effective manpower management policies, role in the delivery of primary health care. and the establishment of mechanisms that will ensure the integrated development of 12.5 WHO's health manpower develop­ health services and manpower. ment programme in I978 and I979 was fully geared to the attainment of an accept­ I2.3 The Health Assembly endorsed able level of health for all by the year 2000, WHO's long-term programme in health in particular through primary health care manpower development and requested the programmes in all countries. Its main THE WORK OF WHO, 1978-1979

objective is to collaborate with Member I2.8 The medium-term programme, States in developing manpower systems however, must be constantly reviewed, that will enable them to plan for, produce, adapted and improved to meet changing manage, and efficiently utilize health per­ health needs and demands. An inter­ sonnel that are sufficient in number and regional meeting of nationals and WHO have the appropriate skills to meet the staff (Brazzaville, December I 978) reviewed health needs of the entire population, par­ progress made, assessed the present status ticularly the most deprived communities of the programme to determine if its such as those in rural areas. To attain this objectives were being fulfilled, and formu­ objective, the tasks of each category of lated strategies for implementation at coun­ health worker must be defined and the try level. It concluded that the medium­ training of each health worker must be term programme was valuable in that it appropriate to the job he or she will be provided a definite plan of action to achieve expected to carry out. the objectives of the General Programme of Work and that the interlinking of activi­ I 2.6 This in turn requires a logical ties over a six-year period would make sequence of activities : health manpower for continuity of action. Moreover, the planning based on the national political medium-term programme would enable framework and national health policies ; provision to be made in the biennal budget education and training (i.e., production) in the light of six-year targets, would of health manpower based on those plans; facilitate evaluation of activities and should and management of the health manpower prove an effective management tool, thus trained. These activities should be especially for intercountry and interregional integrated into a single process. During activities. the ·biennium WHO sought to promote 'this concept of integrated health services I 2.9 The implementation of the and manpower development and to col­ medium-term programme progressed satis­ laborate with Member States in setting factorily during the biennium in spite of up mechanisms to translate the concept financial constraints. Indeed it served to into reality. attract extrabudgetary resources-from UNDP, UNFPA, CIDA, DANIDA, the Inter-American Development Bank, the The medium-term programme Netherlands Ministry for Development Cooperation, the United Kingdom Overseas I2.7 The medium-term programme for Development Administration, the W. K. health manpower development is an action Kellogg Foundation, and others. These programme that comprises (I) an analysis resources in turn contributed to the of the problems to be resolved, (z) a list realization of the programme in its first two of targets and the activities required to years of existence, as described below. attain them, and (3) a breakdown of the specific action to be undertaken in collab­ Revision of the medium-term programme oration with Member States during the years I978-I983.l I2.Io To ensure that programmes remain relevant to the changing health priorities of Member States, some of the 1 Fulop, T. Health personnel to meet the people's activities in the medium-term programme needs. WHO Chronicle, 33: 80-93 (1979). were reviewed in I979· The basis for this

I66 HEALTH MANPOWER DEVELOPMENT

review and for the further reorientation integral part of the programme, and were the principles adopted and the individual research activities are found strategies proposed at the Alma-Ata Con­ in each programme area. In order to guide ference, resolution WHA32.30 on formu­ these activities, an interregional consulta­ lating strategies for health for all by the year tion on health manpower development 2ooo, the conclusions and recommendations research as one element of health services of the Brazzaville meeting (see paragraph research (Geneva, February I978) identified I 2.8 above), and experience over the the problems to be investigated and estab­ preceding two years. The revised pro­ lished priorities. gramme serves as a basis for the dialogue on collaborative activities in health man­ Health manpower planning and power development with Member States, management nongovernmental and intergovernmental organizations, and other WHO programmes I 2. I4 Activities during the biennium and for the preparation of the I982-I983 were oriented towards cooperation with programme budget. Member States in extending coverage of primary health care through planned change, Programme areas m health manpmver and management of change, in the planning, development utilization and distribution of health per­ sonnel. The objectives are : I 2. I I Activities fall into four pro­ effective coordination between edu~ gramme areas : (I) programme planning cational and service institutions ; and general activities; (2) health manpower development of national capability planning and management; (3) promotion for health manpower planning ; of training; and (4) educational develop­ development of national capability ment and support. for management training; I 2. I 2 The first of these covers the promotion of career development coordination of the other three areas and and incentive schemes, including also certain general activities that affect all systems of continuing education, and programmes, e.g., the information service limitation of undesirable migration and research. The information service uses of health personnel. the WHO Chronicle for the publication of a newsletter ("Health manpower news") Health services and manpower development providing information on health manpower plans, programmes and processes; man­ I 2. I 5 Coordination between edu­ agement techniques ; teaching/learning cational and service institutions was the materials ; instruments and processes for object of a two-fold approach : (I) the programme evaluation; and training promotion of a dialogue among all sectors institutions and other learning facilities. involved in health services and manpower Six such newsletters appeared during the development, and (2) the establishing of biennium. mechanisms to ensure coordination of those sectors. As a result, awareness of the con­ I 2. I 3 Research in health manpower cept increased throughout the world and development is an integral part of health countries took action to establish or services research, since the very purpose of improve their coordination mechanisms. health manpower is to provide the services An example of this in the Region of the needed for health care. Such research is an Americas is the Latin American Program THE WORK OF WHO, 1978-1979 of Educational Development for Health I 2. I 8 In the Eastern Mediterranean (funded by various agencies and by govern­ Region, a ministerial consultation on health ments), which continued to promote inter­ services and manpower development sectoral committees for coordinating health (Teheran, February/March I978) brought manpower development within the frame­ together for the first time ministers of work of health services. Among the health and ministers of education from the activities carried out were the project of Member States of the Region. A plan of technical cooperation to improve training action for the functionally integrated devel­ programmes at the University of Nicaragua, opment of health services and health man­ the programme for education and training power resulted, which outlines general of allied health personnel in the Caribbean, principles, measures to be taken by national and the programme for training health authorities, and activities to be undertaken personnel in Brazil. by WH0.2 Egypt, Pakistan, and Saudi Arabia subsequently held national meetings IZ.I6 The European Region continued on the subject, and steps in the same its efforts to improve communication and direction were taken in Afghanistan, collaboration both within the health pro­ Bahrain, Iraq, Kuwait, Sudan, and Tunisia. fessions and also between the health and educational systems and the community. I2.I9 The dialogue between health A study, completed early in I978, on com­ services and manpower development sectors munication and collaboration among health was the subject of seminars for the Region professionals in medicine, nursing, and of the Americas (Caracas, February I978) medical social work was the main document and for the South-East Asia and Western for a working group (Florence, Italy, Pacific Regions (Manila, March I979)­ October I978) that discussed working both in collaboration with the World relationships among those groups of Federation for Medical Education. The workers. The working group was pre­ Manila seminar was followed in the South­ ceded by a study of teamwork between East Asia Region by a consultation (New physicians and nurses, carried out in five Delhi, August I979) to develop country­ countries of the Region (Denmark, specific plans of action for coordination Hungary, Netherlands, Sweden, and the of the two sectors, and in the Western United Kingdom). Pacific Region by a meeting in late I 979 of deans of medical schools who similarly I2.17 The European Region's medium­ discussed intersectoral collaboration. term programme in nursing and midwifery emphasizes the integration of health man­ Planning of health manpower power development and nursing services. As part of this programme, six national I2.2o A series of activities was under­ collaborating centres working in close taken to improve health manpower planning contact with a wide network of participating capability in Member States. A publication centres are conducting standardized studies issued in I978 3 assembled information on of nursing interventions and the personnel 2 World Health Organization. An integrated approach needed to carry out such interventions to health services and manpower development. Report of a effective! y. 1 ministerial consultation (Teheran, I978). Alexandria, 1978 (WHO/EMRO Technical Publications, No. 1). 1 World Health Organization. Evaluation of in- 3 Hall, T. L. & Mejia, A. Health manpower planning: patient nursing practice. Report on a working group. Copen­ Principles, methods, issues. Geneva, World Health Organ­ hagen, 1979 (EURO Reports and Studies, No. 4). ization, 1978.

I68 HEALTH MANPOWER DEVELOPMENT the various aspects of health manpower many subsequent requests to WHO planning, set out the principles of health for cooperation in formulating national manpower planning as an integral part of programmes. overall health planning, and highlighted some of the difficulties commonly encoun­ 12.24 The Regional Office for Europe tered. Guidelines for health manpower began work, initially with the nine countries planning, in the form of a set of procedural of the European Economic Community, steps, were prepared for use in the training on methods for the regular collection of of planners. Following a consultation on information on nursing and midwifery health manpower planning (October 1978), personnel as a basis for estimating man­ the Regional Office for the Western Pacific power needs. also developed a set of guidelines emphasiz­ ing the health manpower planning process, 12.25 Two region-wide studies on man­ the entry-points for undertaking such power needs, in oral health and in environ­ planning, and the relationship of the mental health, were initiated in the Eastern process to country health programming. Mediterranean. At the end of 1979 both sets of guidelines were ready for field testing. 12.26 The failure to relate manpower requirements to prevailing health needs and 12.21 In the African Region, the cur­ to the socioeconomic situation of the coun­ ricula of health development centres, in try is an obstacle to realistic health man­ particular the centre attached to the power planning. Baseline information is Institute of Public Health, Cotonou (Benin), often weak owing to inadequate national were reoriented to include the method­ information systems. WHO has therefore ology of country health programming. tried to find alternative methods of health manpower planning that are suited to the 12.22 In the Region of the Americas, technical and financial capacity of health the concept of health manpower planning information systems. A simple approach is widely accepted and the majority of has been developed for health problems ministries of health have set up special that cannot await the results of large-scale units for this purpose. The Andean coun­ surveys over a long period of time. It tries-Bolivia, Columbia, Ecuador, Peru, consists in eliciting information from and Venezuela-decided through the Hipo­ selected health workers, administrators lito Unanue Agreement to pool the results and community representatives as to what of their experience in health manpower they consider to be the health needs of the planning in order to establish a master community and its manpower require­ system of information that would serve as ments. The methodology for such an an example for other countries. The approach was field-tested in Colombia Organization cooperated with the Ministry during the biennium and the final report of Health of Columbia in conducting the is expected early in 1980. first international course in health man­ power planning (Bogota, I 978). 12.27 One of the recommendations of the Alma-Ata Conference was that govern­ 12.23 In the South-East Asia Region, ments should define the roles and functions an intercountry workshop on health man­ of health workers in the delivery of primary power studies (Bangkok, 1978) aroused health care. A consultation on systematic considerable interest, as evidenced by the approaches to task analysis in maternal and THE WORK OF WHO, 1978--1979 child health care (Geneva, August I979) I 2. 3 I In the African Region high considered alternative methods for func­ priority was given to integrating manage­ tional analysis or "work studies", and how ment training into the curricula of all health such studies could be used in health man­ institutions. A network of national centres power planning. The emphasis was on for training in health management is being simple procedures adapted to the needs of established with institutions in Benin, the country concerned. Mozambique, Niger, Nigeria, Senegal, the United Republic of Cameroon, the United Republic of Tanzania, and Zaire. Management of health manpower 12.32 In the Americas PAHO/WHO I 2.28 The Alma-Ata Conference recom­ collaborated with the Pan American Feder­ mended that governments should provide ation of Associations of Medical Schools and appropriate management training to differ­ the Latin American Association of Schools ent categories of health workers. Earlier of Public Health in offering training pro­ in I978 the Health Assembly had advo­ grammes in public health. Six countries­ cated the need for a unified managerial Costa Rica, Dominican Republic, El Sal­ process for national health development vador, Guatemala, Honduras and Nicar­ and urged .Member States to provide appro­ agua-undertook a programme to train priate training and continuing education supervisory personnel and reorient them to in managerial processes for all health the delivery of primary health care The workers, particularly health administrators Latin American Centre for Educational (resolution WHA3 1.43). Technology for Health, Rio de Janeiro, actively participated in this type of training ; I2.29 The subject selected by the Health a programme began in Brazil and Colombia Assembly in I978 for the organizational to reinforce training in the administration study to be undertaken by the Executive of health care in Latin America. Board was : "The role of WHO in training in public health and health programme 12.33 The Regional Office for Europe management, including the use of country continued to support the nine-month health programming". The study was course for public health administrators held designed and was under way at the end annually (in Russian and English) at the of I979· Central Institute for Advanced Medical Studies, Moscow, and the two four-week 12.30 WHO is also promoting training summer courses held respectively at the in public health management as a coop­ Nuffield Centre for Health Services Studies, erative endeavour carried out through a University of Leeds (United Kingdom) and network of national and intercountry at the International Summer School of the institutions. As a first step, a programme University of Oslo. A working group on of continuing education to meet manage­ the design of training in health planning ment difficulties in the delivery of primary and management (Berlin (West), July I979) health care was initiated in Burma, Costa considered how to develop or intensify Rica and Sri Lanka, in which WHO coop­ such training in the European Region. erated with the national health authorities An inventory of the various institutions in planning training programmes on the throughout the world that can be used basis of management problems specifically for health management training was com­ identified as hindering such delivery. pleted ; it includes institutions with train-

qo HEALTH MANPOWER DEVELOPMENT ing programmes in general management session of the Regional Committee (Hel­ and public administration, which are often sinki, September 1979) the theme of which more developed than those in the health was, "Continuing education of health per­ sector and are also suitable for training sonnel and its evaluation". This interest is health workers. also reflected in the large number of courses on the subject organized in the Region. Continuing education A working group on continuing education of health personnel as a factor in career 12.34 The Alma-Ata Conference recom­ development (Budapest, 1978) brought mended that all levels of health personnel together participants with experience in be provided with appropriate incentives, planning, organizing and evaluating courses including opportunities for further training of continuing education, with a view to or continuing education. The development determining how programmes of con­ of health services in rural areas and the tinuing education can support the career emphasis on primary health care have development of health workers and how created new demands for the continuing to encourage and expand this aspect. education of health personnel, and Member States are coming to recognize the need for 12.3 7 In the Eastern Mediterranean comprehensive national programmes for Region, WHO participated in the inaugural this type of training. An interregional meeting of the Supreme Council of the Arab seminar on continuing education of health Board for Medical Specialization (Kuwait, personnel (Washington, DC, April/May January 1979), sponsored by the Technical 1979), bringing together officials of minis­ Secretariat of the Council of Arab Ministers tries of health and educators from countries of Health in order to promote the develop­ throughout the world, reviewed national ment and upgrading of postgraduate and policies, programmes and experience, and continuing education programmes for phys­ proposed activities for cooperation and for icians in the Region by setting up specialty the further development of continuing boards in medicine, surgery, obstetrics, education of health personnel. The first gynaecology and paediatrics. version of an operational guide for a system 12.38 For several years in the Western of continuing education was presented to Pacific Region WHO has been providing the seminar and will be field-tested in the refresher training to medical officers in near future. the Trust Territory of the Pacific Islands; 12.3 5 In the Region of the Americas, the health manpower development pro­ an agreement was signed in 1978 with the gramme of the Territory includes con­ ministers of health of Bolivia, Colombia, tinuing education for ten categories of Cuba, Dominican Republic, Guatemala health worker. and Honduras for a three-year project in which systems of continuing education Migration of health manpower would be established for health personnel 12.39 The exodus of health manpower working in rural areas. continues to be of concern to Member 12.36 The growing interest of the States. The results of a WHO study were Member States in the European Region in published in 1979/ and an abridged version continuing education programmes for all 1 health workers found expression in the Mejia, A. et al. Physician and nurse migration: Analysis and policy implications. Geneva, World Health Technical Discussions at the twenty-ninth Organization, 1979. THE WORK OF WHO, 1978-1979 was prepared in French by the Centre de traditional birth attendants-and on pre­ Sociologie et de Demographie medicales, paring teachers for those categories of Paris. A special case-study on the United health workers. The objectives were : States of America, sponsored by the to develop educational institutions, Sandoz Institute for Health and Socio­ with emphasis on the intermediate economic Studies, Geneva, and by WHO and auxiliary levels ; examined the extent of migration of phys­ to design and develop task- and com­ icians and nurses from various countries, munity-oriented training programmes its causes, and its consequences. One of the for all levels of health personnel that conclusions of the study is that undesirable have special relevance to the needs migration cannot be controlled by any of of underserved populations and can the methods usually employed in the past: be replicated ; and it can be reduced only when a country produces the categories and numbers of to provide advanced education for health personnel that it can effectively health personnel, including the subject absorb and principally when training of all matter component of teacher training. health personnel is reoriented to meet priority needs in health care. This in turn Trainingfor primary health care entails a coordinated system for the devel­ 12.42 The Primary Health Care Worker: opment of health services and health Working Guide, Guidelines for Training, Guide­ manpower. lines for Adaptation was first published in 1977. During the biennium it was a~aptC::d 12.40 An examination of the results to local conditions in -: I 5 countnes 1n of the study, which is being prepared for all six regions, and was translated into local publication, should enable each Member languages. This guide has now been State to pinpoint the factors that influence reviewed and new chapters have been the migration of health personnel and added, in particular a chapter dealing with determine in what ways, if any, WHO can community participation. The revised cooperate in designing and implementing English edition was published. 1 a plan of action to curb undesirable migration. 12.43 Another guide-On Being in Charge : A Guide for Middle-/eve/ Management in Primary Health Care-was developed for Promotion of training health personnel working at the heal~h centre or dispensary as reference matenal 12.41 The development of personnel for use in organizing, guiding and super­ for primary health care, and the strength­ vising the work of health workers at the ening of the capabilities of Member States peripheral level. An experimental version for implementing and evaluating their of the guide was being tested at the end training programmes for health workers of 1979. through an exchange of experience, formed the core of this programme area. Activities 12.44 The report was published of an concentrated in the main on developing expert committee on the training and and promoting training strategies that are relevant to community health needs­ 1 World Health Organization. The primary health especially for peripheral, auxil~ary ~nd worker: Working guide, guidelines for training guidelines intermediate-level health workers, mcludmg for adaptation, revised edition. Geneva, 1980. HEALTH MANPOWER DEVELOPMENT utilization of auxiliary personnel for rural 12.46 In the African Region, a work­ health teams in developing countries 1 with shop on primary health care was organized a view to defining strategies for developing by the University Centre for Health the teamwork approach for the various Sciences, Yaounde (March 1978), and a categories of health personnel engaged in guide was prepared to facilitate the integra­ primary health care. The committee tion of primary health care development stressed that it is advisable to recruit into health manpower development pro­ trainees from the village or area to which grammes. Another workshop (June 1979) they will eventually return to work ; the at the Lome regional training centre newly trained health worker will then be examined didactic material produced by familiar with local culture and customs and the centre for the training of community will be more readily accepted by the local health workers. In the Region of the people. Traditional health practitioners Americas, an evaluation was made of the in the community should be considered programme for training allied health per­ an additional source of potential health sonnel in the Caribbean ; the evaluation manpower. The committee's report was mission concluded that the programme discussed at an interregional workshop was of high priority and should continue on the development of health teams in to receive the support of WHO. In the rural work (Tacloban, Philippines, October Western Pacific Region, the use of medical 1979), at which country-specific plans of assistants is being increasingly promoted: action for training rural health teams were there are training programmes in Fiji and discussed. As a follow-up to the expert Papua New Guinea, and WHO is collab­ committee, an interregional study on the orating in a new training project that has training and utilization of community been initiated in Tonga. health workers began in I 3 Member States in all six regions. 12.47 Nursing personnel provide a con­ siderable proportion of the health care in 12.45 A study tour on the training and most countries and form the bulwark of utilization of barefoot doctors in community primary health care services in rural areas. health services (China, August 1978) enabled A workshop cosponsored by WHO and participants to observe the achievements the International Council of Nurses (Nai­ of this type of personnel in both urban and robi, September 1979) defined the role of rural settings. Eighteen participants from nurses in the planning and implementation developing countries in all regions thus of primary health care, and drew up the had an opportunity to learn how com­ framework for a plan of action through munity health services in China are planned, which the member associations of the organized and implemented, and how the Council could effectively promote and barefoot doctor is trained and utilized to support primary health care at national and extend the coverage of health services to international levels. Since the participants the total population. They were also able in the workshop were leaders of the nursing to determine which approaches could be profession from 6 3 countries, they are in a adapted to primary health care services, position to influence nursing services, especially in rural areas in their own education and research, and to reach about countries. one million nurses throughout the world.

12.48 Facilitating Teaching/Learning with 1 WHO Technical Report Series, No. 633, i979. Modules : An Approach for Nurse Midwife

173 THE WORK OF WHO, 1978-1979

Teachers, the publication of a WHO collab­ the United States of America) in holding orating centre which appeared in I 977 ,I the first international conference on the has been the main source of guidance on role of the infection-control nurse in the training modules, and a questionnaire surveillance, prevention and control of designed to evaluate its usefulness was hospital-associated infections (Copen­ distributed to several hundred users in all hagen, I978). Sixty-six participants from regions. The use of the modular approach 27 countries discussed the problem of in the continuing education of all categories nosocomial infections ; defined the role of of health personnel (physicians, nurses, the infection-control nurse as an integral midwives) working in rural areas was but independent member of the surveil­ evaluated in the Philippines towards the lance, prevention, and infection-control end of I979, to determine the effectiveness team ; and provided guidelines for the of the approach as compared with tra­ education and training of such nurses. ditional methods in terms of cost and of The Regional Office also participated in the time required for learning how to developing reoriented nursing education use it. programmes in a number of countries, including Belgium, Iceland and Italy, and I 2 ·49 In the African Region the inter­ also in Berlin (West). national teaching staff at the regional postbasic nursing education centres in I2.p In the Western Pacific Region, a Dakar and Yaounde are gradually being study was carried out in Papua New Guinea replaced by nationals. An evaluation of to determine what roles are currently per­ the work of both centres showed that a formed by nurses and ascertain existing high proportion of their graduates are pathways for their career development. teaching in national schools for nurses and A working group was held on the collab­ midwives and that the rest are working as orative role of WHO in nursing and mid­ head nurses, senior nurses, or adminis­ wifery in the South Pacific (Suva, I978). trators in hospitals. In Malaysia, the functions of the rural midwife are being expanded to those of a 12.50 In the South-East Asia Region, multipurpose community health worker. nursing curricula were adapted to reflect The postbasic programmes in nursing edu­ the community health approach, and guide­ cation, nursing administration and com­ lines were prepared for community-oriented munity health at the Port Moresby College training. An intercountry workshop on of Allied Health Sciences, Papua New planning for continuing education for Guinea, are already producing graduates nursing personnel was held at the Regional who take up posts in teaching and admin­ Office (September I978). istration. In addition, as a result of national and interregional workshops in Papua New 12.51 The Regional Office for Europe Guinea and in the Philippines, 62 modules collaborated with an independent group of for nursing and midwifery instruction were nurses from five countries (Canada, Den­ developed. mark, Sweden, the United Kingdom, and I 2. 53 The Alma-Ata Conference recom­ mended the use of traditional birth attend­ 1 British Life Assurance Trust Centre for Health ants in primary health care where appro­ and Medical Education. Facilitating teaching/learning with modules: An approach for nurse midwife teachers. priate, a recommendation that gained London, 1977. national support in many countries and has HEALTH MANPOWER DEVELOPMENT steadily attracted the interest of health intergovernmental and nongovernmental authorities. Several activities were under­ organizations in carrying out these strat­ taken to strengthen and extend training egies, which include research, the develop­ programmes for this category of health ment of appropriate teaching/learning worker. materials, and exchange of information.

12.54 A field guide to the tra1n1ng of Community-oriented educational programmes traditional birth attendants was published.1 It gives guidance on the training of tra­ I 2. 57 Activities were undertaken to ditional birth attendants, outlines pro­ increase the relevance of educational pro­ cedures for evaluating their training and grammes to the health needs of communities utilization, and explains how to link them and to improve the effectiveness of the effectively with the organized health sys­ teachingflearning process. Among them tem by means of continuous coordination was the publication of the first volume of with training institutions and referral Personnel for Health Care : Case 5 tudies of centres and by the formulation of appro­ Educational Programmes,a a series to dis­ priate official policies. seminate information about educational programmes that are breaking with tradi­ I 2. 5 5 In order to exchange information tion in that they are specifically oriented to on the utilization of traditional birth community health needs. Such pro­ attendants, national investigators from eight grammes are attempting to make the countries (Ecuador, Honduras, Philippines, teachingflearning process more effective by Senegal, Sierra Leone, Sri Lanka, Sudan basing it on community problems, intro­ and Thailand) began to prepare case studies ducing the concept of integration of health describing their training and utilization services and manpower development, and showing how the constraints on these emphasizing "active" learning, and using processes could be resolved. An annotated appropriate technology. bibliography on the training, utilization and evaluation of traditional birth attend­ I2.58 Another activity to support edu­ ants was issued in document form in cators attempting to develop community­ late I979· 2 oriented educational programmes was the formation by WHO of a global network I 2. 56 As a further step, an interregional of institutions offering such programmes. consultation (Mexico City, December I979) At a meeting in Kingston (June I979), defined national strategies for the training some 20 directors of community-oriented and utilization of traditional birth attend­ educational programmes agreed to collab­ ants, as a way of extending primary health orate with and offer support to other in­ care services to underserved populations, stitutions with similar objectives. Such particularly those in rural areas. It high­ support includes the exchange of infor­ lighted the role of WHO, and of other mation, learning material, and personnel ; the organization of workshops for the 1 World Health Organization. Traditional birth staff of the institutions ; the sharing of attendants. A field guide to their training, evaluation and arttculation with the health services. Geneva, I 979 (WHO Offset Publication No. 44). 3 Katz, F. M. & Fiilop, T., ed. Personnel for health 2 Traditional birth attendants. An annotated bibliography care: Case studies of educational programmes. Geneva, on their training, utilization and evaluation. (WHO docu­ World Health Organization, 1978 (Public Health ment HMD/NUR/79· 1-English only). Papers, No. 70).

I75 THE WORK OF WHO, 1978--1979

expertise ; and participation in research I 2.62 In the Western Pacific Region, and developmental activities. two study missions were arranged for teaching staff from China. The first, a I 2. 59 In the African Region, networks group of ten senior faculty members from of health development or training centres three medical schools, spent two weeks are being gradually established. The at the regional training centre, Sydney Institute of Public Health, Cotonou (Benin) (January I979) studying undergraduate was designated a regional health develop­ medical education. The second group ment and training centre and its training (September I 979) visited the European, programme was redesigned to give it American and Western Pacific Regions to community orientation and permit active observe the organization and management student participation. The fifth meeting of higher education. of deans and directors of training establish­ ments for health sciences in Africa approved Information on traimng institutions a proposal to set up an African network of national centres for training specialists. I2.63 The fifth edition of the World Directory of Medical Schools/ gives informa­ I2.6o Representatives from the African, tion on I I I 6 medical schools (using I 97 5 South-East Asia, Eastern Mediterranean, as the main year of reference)-an increase and Western Pacific Regions attended the of I 54 over the number reported in the eighth meeting of directors of schools of fourth edition, which used I 970 data. public health (Bangkok, I979)· The The directory describes the pattern and meeting reiterated its support for integrated administrative structure of undergraduate development of health services and man­ medical education in each country and gives power, and outlined a strategy for related selected data on each medical school, research. including criteria for and the process of student selection, types of curriculum design, instructional methods, and pro­ I 2.6I In the South-East Asia Region, cedures for evaluating student performance. an intercountry consultation (October I 978) considered the development of postgraduate training in the Region and recommended I 2.64 The African Region prepared a that the role of the specialist at the inter­ directory of training institutions for health mediate level of health care delivery should personnel in the Region which gives details be strengthened. This would mean produc­ of the types of training programme and the ing staff who, although specialized in one material resources available in each in­ discipline, would also have a general stitution. It also includes details on the knowledge of other disciplines besides networks of national centres for (a) pro­ being competent in administration and duction and distribution of teaching management, educational methodology, and material and (b) training of specialists. communication skills. An intercountry seminar (Surabaya, Indonesia, June I979) Fellowships reviewed the extent to which medical I2.65 The award of fellowships is an education has been reoriented towards important part of WHO's work. Consider­ community health needs and proposed able effort is exerted to ensure that oppor- country-specific strategies and approaches for developing task- and community­ 1 World Health Organization. World directory of oriented curricula. medical schools, fifth edition. Geneva, I 979· HEALTH MANPOWER DEVELOPMENT

tuntttes for study meet countries' needs mary health care. They have the following and that fellowships are efficiently and objectives : economically administered as part of the - development of a systematic approach general programme of technical coop­ to educational planning and tech­ eration with Member States. During the nology, including teacher training ; biennium I978-I979 WHO awarded 6798 and fellowships for study (see Table I2.I) and 7084 fellowships for participation in meet­ - development and/or provision of ings or for other educational activities relevant health instructional material, (courses, seminars, workshops) organized including textbooks. by WHO. Teacher training I 2.66 Efforts were made to place fellows in an environment that resembled that of I2.69 The Alma-Ata Conference recom­ their home country. In I978, for example, mended that due attention should be given 62.4% of fellows were placed in their own to the preparation of teachers of health region (73.6% in the African Region, workers. WHO has been engaged in several 88.9% in the Region of the Americas, collaborative activities with Member States 40.6% in the South-East Asia Region, to develop teacher-training programmes 89.5% in the European Region, 41.4% in at regional and national level, mostly by the Eastern Mediterranean Region, and way of workshops or consultations on 66.6% in the Western Pacific Region). In educational theory and processes. many cases fellows studying in regions other than their own do so in countries 12.70 One important activity during similar to their own ; for example, fellows the biennium was the continuation of from developing countries of the Eastern the global teacher-training programme, Mediterranean Region may study in India. launched in I969, and a report issued in I979 reviewed this activity from its I 2.67 A conference on regional coop­ beginnings. The original programme eration in the WHO fellowships programme had envisaged the establishment, in stages, was held in the Western Pacific Region of interregional, regional, national, and (February I979) at which representatives institutional centres that would attempt discussed changing trends in training and to increase the relevance of the teaching/ emphasized the importance of the fellow­ learning process for health workers to the ships programme as exemplifying the real health needs and demands of the policies that guide WHO's programmes of population as a whole. In the first stage collaboration with Member States, e.g., an interregional teacher training centre technical cooperation among developing was established at the Center for Edu­ countries. cational Development, University of Illinois (United States of America) that would train staff for the regional centres, of which eight were set up-in Bangkok, Kampala, Educational development and support Mexico City, Peradeniya (Sri Lanka), Rio de Janeiro (Brazil), Shiraz (Iran), Sydney I2.68 Activities under this heading are (Australia), and Yaounde. Six of the focused on the stimulation of educational directors of these regional centres and one planning and processes in support of pri- assistant director completed a one-year THE WORK OF WHO, 1978-1979

Table 12.1 Distribution of fellowships, by subject of study and by region, 1978-1979

South­ Eastern Region East Mediter- Western African of the Asia European ranean Pacific Subject of study Region Americas Region Region Region Region Total

Public health ad ministration . . . . . 391 149 176 47 66 107 936 Hospital and medical care adminis­ tration ...... •... 11 47 36 16 73 20 203 Construction of health institutions . 11 1 3 4 19 Medical librarianship 2 21 6 2 31 Subtotal 404 228 212 64 148 133 1189

Environmental sanitation . 148 50 167 201 38 58 662 Food control. • 1 41 21 11 10 17 101 Subtotal 149 91 188 212 48 75 763

Nursing and midwifery . 96 59 40 13 54 26 288 Public health nursing .••..•• 97 a 13 3 6 22 149 Medical social work 2 4 2 1 9 Subtotal 195 71 53 18 60 49 446

Maternal and child health 47 105 173 117 52 23 517 Paediatrics and obstetrics 11 24 20 13 22 13 103 Subtotal 58 129 193 130 74 36 620

Mental health 9 47 47 21 25 14 163 Health education. 64 a 45 3 15 13 148 Occupational health 5 3 23 19 19 20 89 Nutrition. 9 110 26 6 a 14 173 Health statistics . 6 48 34 38 20 21 167 Oral health 27 26 26 6 16 55 156 Rehabilitation .....• 26 26 20 22 30 6 130 Control of pharmaceutical and bio­ logical preparations 9 19 29 13 34 24 128 Subtotal 155 287 250 128 167 167 1154

TOTAL - HEALTH ORGANIZA- TION AND SERVICES _ _=.:96:.:1 ___..;;8:.:.06=----..::89:..:6:...._ ____:5.:::52=-----...:.49:..:7:.__ _ __:.46:..:0:...._ ___4:..._1:..:7=-2 Percentage 72% 60% 56% 80% 46% 59% 61% ------~------Malaria ...... 48 44 43 7 63 35 240 Sexually transmitted diseases 3 15 10 1 15 7 51 Tuberculosis • • . . • . . • 12 23 39 20 20 114 Other communicable diseases 58 150 97 12 53 16 386 Laboratory services . . . • . 62 86 119 27 92 57 443 Chemotherapy, antibiotics . • 2 2 2 6 TOTAL- COMMUNICABLE DISEASES_~18~3___ _;;3~18=-- __..::31:..:0:.__ ___~49:...._ ___..::24~3:....__~13:..:7:.__ __:.__1..;;2:.:4..::_0 Percentage ------14% 24% 20% 7% 23% 17% 18% Surgery and medicine 17 7 41 18 38 15 136 Anaesthesiology • • 11 6 1 25 17 60 Radiology . . . 54 10 20 4 61 35 184 Haematology • ...... • . . . . 9 5 10 2 20 4 50 Other medical and surgical specialities __3:::3:...._ ____:2:._4:...._ ___8:::6:...._ ___..;;3:.:.6 _____7:..:2:...._ __..::2:::.0 _____:2:.:.7.:_1 Subtotal ------124 46 163 61 216 91 701 Basic medical sciences . . . 24 11 49 13 45 30 172 Medical and allied education • 5 154 166 16 59 46 446 Undergraduate medical studies __.::,36:....______4;______..:.:10:.._ __...:.1..:..7 ______:6:.:__7 Subtotal ------65 165 219 29 114 93 685 TOTAL - CLINICAL MEDICINE, BASIC MEDICAL SCIENCES, AND MEDICAL AND ALLIED EDUCATION_~18:..:9:.__ __..;;2:.:.1..:..1 ____:3:::82:...._ ___..::90:...._ ___..::33.:::0:...._ _ __:.18:._4:...__ ___1:..._3:..:8:.:._6 Percentage ------14% 16% 24% 13% 31% 24% 21% GRAND TOTAL 1 333 1 335 1 588 691 1 070 781 6 798"

• 3 267 during 1978 and 3 531 during 1979. HEALTH MANPOWER DEVELOPMENT

training programme at the interregional Health Personnel 1 continued to be used centre. Short workshops were also held extensively. This handbook, designed to to train staff from regional centres and other help teachers in their training activities, educational leaders. By the end of the first was field-tested and is being revised on the stage most of the regional centres were fully basis of feedback obtained from its users operational and were using trained staff. both in their working situation and in work­ Under the terms of the original agreement, shops or consultations. in I 97 3 the Center for Educational Develop­ ment ceased to act as an interregional 12.74 A survey on the use of learning centre. objectives is being carried out in institutions training nurses and physicians, with the 12.7I By early I978 more than 700 collaboration of two nongovernmental workshops, involving more than I 5 ooo organizations, the International Council participants, had been held to improve the of Nurses and the World Federation for training of teachers, and a number of Medical Education. The purpose is to graduate programmes were being offered. find out which institutions have established Six of the eight centres are still operating a list of general educational objectives for as regional centres. The centres in Kampala the type of personnel they are training and, and Yaounde have been redesignated as most important, to what extent those national centres, of which there are many objectives are relevant to the assessed health others, e.g. in Manila, Pondicherry (India), needs of the population to be served. and Seoul. All the regional teacher-training centres are engaged to some extent in the I 2. 7 5 In view of the recognized shortage production and dissemination of teaching/ of teaching personnel, particularly in devel­ learning material, and some have carried oping countries, the possibility of using out research in education. Centres have students as members of the instructional been established in different trammg team was investigated. A consultation was institutions throughout the world as an convened (December I978) to review the offshoot of this programme and their potential of peer learning as a way to con­ number is still growing. tribute to the teaching/learning process. Most health workers, especially those at the peripheral level of the health services, 12.72 The report reviewed in detail spend considerable time instructing others ; the structure, functions, and teaching teaching as a student therefore provides activities of the various centres and out­ an experience directly related to the future lined some of their problems. It attempted professional life of the student. The report to assess the impact of the programme on of the consultation is intended for teachers the health manpower development of and administrators and provides guidelines Member States and the influence it had had on ways and means of facilitating the parti­ on the hundreds of thousands of teachers cipation of students in the teaching/learning around the world. It described the research process. carried out, and pointed to the constraints which hindered the achievement of some 12.76 The evaluation of programmes, of the programme's objectives. and of the performance of students, teachers,

1 12.73 As an aid to the teacher-training Guilbert, J.- J. Educational handbook for health personnel. Geneva, World Health Organization, 1977 workshops, the Educational Handbook for (WHO Offset Publication No. 35).

I79 THE WORK OF WHO, 1978--1979

and supervisors, is an essential step in planning and implementation of teacher­ health manpower development, and a training programmes held at BLAT in guide for educational programme evalua­ London, the participants recommended tion was published during the biennium.1 that a network of WHO collaborating centres for teacher training should be set up. I2.77 In the African Region, as part of WHO has agreed to collaborate with the a regional network of national teacher­ Medical Faculty of Semmelweis University, training centres, two national centres are Budapest, in developing teacher training being set up-at the Faculty of Medicine, there. Ife (Nigeria), and at the Faculty of Medicine and Pharmacy, Dakar. Twenty-five work­ I2.8o In the Eastern Mediterranean shops on teaching methodology, attended Region, an assessment was made of the by more than 400 teachers, had been extensive activities carried out at the organized by September I979· regional teacher-training centre at Shiraz University (Iran). The meeting to discuss 12.78 In the Region of the Americas the assessment (Khartoum, February I979) the Latin American Centers for Educational concluded that, although there is still a Technology in Health, in Mexico City considerable need for strengthening the and Rio de Janeiro, continue to function centres responsible for teacher training in as the focal point for technical cooperation the Region, there is now the "critical mass" in that field in the region. The Mexican of competent persons to carry out this centre carried out activities not only in institutional developmental work. The Mexico but also in Argentina, Chile, Peru, journal The Learner, published jointly by the Uruguay, and Venezuela. The centre in regional teacher-training centre, Shiraz Rio de Janeiro organized I6 courses there, (Iran) and WHO, continued to serve as an attended by about 300 participants, and effective means of communication between also offered courses in Columbia, Ecuador those concerned with teaching. In addition and Peru. to the substantial number of national work­ shops (conducted by nationals), itinerant 12.79 Among the many teacher-train­ workshops on educational planning and ing activities in the European Region were evaluation were held in Amman and in two workshops : one on curriculum devel­ Damascus under the auspices of the opment in the education of health pro­ regional teacher-training centre. fessionals, conducted by the Institute for Research in Education and Evaluation, I 2. 8 I In the Western Pacific Region, Berne (I978), and the other on modern the regional teacher-training centre in trends in medical teacher training and their Sydney continues to play an active role relation to new developments in health (see paragraph 12.70 above). Two national services delivery, held in Hindas (Sweden). teacher-training centres are operating-in Two workshops on educational method­ the Philippines and the Republic of Korea­ ology were organized in London by the and the Government of Malaysia has British Life Assurance Trust Centre (BLAT) indicated that it will establish such a centre and WHO. As a result of a seminar on initially for the training of allied health professionals. Workshops were organized and work on curricula for different 1 Katz, F. M. Guidelines for evaluating a training programme for health personnel. Geneva, W odd Health categories of health personnel was carried Organization, 1978 (WHO Offset Publication No. 38). out in many countries of the Region. Plans

I80 HEALTH MANPOWER DEVELOPMENT

were made for a diploma course in educa­ manuals (in English) in its collection of tion of health personnel at the Port Moresby materials and equipment for distribution College of Allied Health Sciences, which to developing countries. would take in teachers of allied health professionals who do not meet the entrance I 2.84 The Manual of Basic Techniques for requirements for the master's degree course a Health Laboratory was ready for publica­ offered at the regional teacher-training tion at the end of I 979· It provides a centre. copiously illustrated guide to health lab­ oratory practices, giving particular attention to low-cost, simple methods. Learning materials I2.85 WHO cooperated with the Royal I2.82 There is a general shortage of Tropical Institute, Amsterdam, and the learning materials for the training of health schools of tropical medicine in Liverpool workers, but a number of steps have been and London in developing a series of taken to remedy this situation. One audiovisual teaching aids (MEDDIA). This thousand sets of a source library in English is an international slide and microfiche bank for health teams, each set consisting of on ten groups of important tropical diseases, 38 books, were assembled and despatched including malaria. So far, a set of ten slides for free distribution to selected training and microfiches, with short accompanying institutions in developing countries. They texts, dealing with the principal parasitoses will not only provide a comprehensive has been produced. collection of source material for teachers of health auxiliaries, but will serve as a I 2.86 With a view to developing a net­ basis for the production of learning work of national centres for the production materials adapted to their specific local and distribution of learning materials in the situation. A further 5oo sets of the source African Region, a survey of resources is library in French are being prepared for being made in five countries-Ghana, distribution in French-speaking countries. Mozambique, Nigeria, Senegal and the Each set is for use with a teacher's guide United Republic of Cameroon. In the that has been extensively field tested : Region of the Americas the PAHOJWHO Teaching for Better Learning : A Guide for health textbook programme is being Teachers of Health Staff This guide should expanded to include manuals, teaching help teachers of health auxiliaries to develop modules, and audiovisual materials. This curricula that are relevant to their com­ expansion is primarily oriented towards munity's health needs, to use these curricula auxiliary and technical health personnel. so as to facilitate the learning process, and The European Region prepared two work­ to prepare their own learning materials books, one on the organization of nursing within the limited resources of teaching and midwifery services, and the other on institutions in developing countries. the nursing process, together with a wide selection of other material on design of the I2.83 Nine manuals for the REMAHA nursing process. Following surveys in collection (Reference materials for health Jordan and Sudan, a programme was auxiliaries and their teachers) were trans­ started in the Eastern Mediterranean Region lated into Portuguese for distribution in for the production of learning materials in Portuguese-speaking Africa, in close coop­ Arabic for front-line and intermediate-level ration with UNICEF. UNICEF has also health workers engaged in primary health included a number of the REMAHA care. THE WORK OF WHO, 1978-1979

12.87 The educational technology can only be modest. It may, however, resources and display centre, Geneva, was be said that the programme has been expanded to allow the dissemination of firmly directed towards primary health; information on teaching aids and techniques that it is a balanced programme which for all types of training schools and in deals with all three elements of health particular for training programmes carried manpower development (planning, "pro­ out at the peripheral level of health care duction" and management) ; and that the delivery. radical change it aims at should ensure the relevance of the national health manpower 12.88 The development of flow charts development process to the real needs and began in 1977 (in the health context, these demands of the population. The activities are diagrams showing the logical steps described above are all elements in a logical involved in reaching decisions on patient chain of action leading to the ultimate management). During the biennium, work attainment of health for all by the year zooo. on these charts was further expanded to ensure that training was more problem­ oriented and to help unsupervised health Examples of activities to develop health workers at the peripheral level of the health manpower in other programmes services to improve their skills. One set of 12.91 The development of health man­ charts on diagnosis and management was power is an integral part of nearly all 1 published, together with a teacher's WHO's programmes, and the activities 2 manual. Another set of charts demonstrates carried out to develop various categories the management of obstetric emergencies of health manpower and provide training in rural or isolated situations. These two in specific skills within those categories sets, together with sets of flow charts on form part of their technical work. Examples mental health problems, are now under­ are given below. going controlled trials in over 40 countries. Health manpower planning and management I 2.89 In selected villages in the Sudan, a project in educational communication 12.92 The Expanded Programme on was under way in 1979 to help village Immunization gave training in planning health workers in their essential task of and management during the biennium to health promotion. The techniques and 872 national and international staff from materials developed will be adapted for more than 100 countries; they included use in other developing countries. This senior- and middle-level programme man­ project was combined with a number of agers and intermediate-level health workers research activities on nonverbal com­ as well as physicians, nurses, midwives munication, as being one way by which and others. The training was given by the health worker can get the health message means of self-instructional modules based across to an illiterate population. on activities related to immunization ser­ vices. Certain aspects of management were 12.90 The achievements of the first stressed, e.g., the setting of priorities and two years of the reoriented programme objectives, supervision, evaluation, and promotion of community participation. 1 Essex, B. Diagnostic flow charts. Experimental Intensive efforts are now being made to have edition. Geneva, World Health Organization, 1978. relevant parts of the training programme on 2 Essex, B. A manual for teaching and evaluating diagnostic flow charts. Experimental edition. Geneva, immunization included in the curricula of World Health Organization, 1978. institutions training health workers.

182 HEALTH MANPOWER DEVELOPMENT

12.93 The European Region under­ pines to observe the organization of took a series of pilot studies on manpower family planning services within the health requirements in environmental health dur­ system. ing the biennium. As a result of these studies, and following a consultation on I 2.96 Health education is one of the environmental health planning and develop­ principal elements of primary health care ment, a set of guidelines on manpower and an increasing effort was made to include planning was issued in I978 ; they incor­ it in the curricula of trainees who will be porate the findings of the pilot studies, working at the peripheral level of the health and include a series of tables illustrating services. In Nigeria, WHO, in conjunction the skills required of each category of with the Department of Social and Pre­ personnel in environmental health. They ventive Medicine at the University of were distributed to all Member States of Ibadan, produced guidelines on health the Region. A similar set of guidelines education for community health workers. for the planning of manpower for environ­ mental health work is being developed for r 2.97 To help front-line health workers use in developing countries. to acquire additional skills, a course on diabetes for auxiliary personnel was organ­ ized in the South-East Asia Region and Training of manpower for primary health care also a postgraduate workshop on diabetes for physicians (Bangladesh, I978). A I 2.94 During the biennium, the train­ postgraduate course on diabetes was organ­ ing of manpower to support primary health ized in Kenya (I 978) and two symposia care was emphasized throughout the (I979)-one in Geneva, on health education Organization. The UNICEF /WHO Joint in diabetes, and the other in Dubrovnik, Committee on Health Policy (January I979) Yugoslavia, on the delivery of health care reviewed the programme of support to for diabetes in developing countries. training in maternal and child health care within primary health care. The object I 2.98 In the Region of the Americas, of this support is to promote national self­ various countries have taken measures for reliance by strengthening national capa­ disability prevention and provision of rehabili­ bilities for training all levels of health tation services at community level. In workers, workers in other development Mexico, community health workers are sectors, and members of the community. being trained to identify disabled persons The training strategy includes the team in the community and to prescribe simple approach, extensive field training, and rehabilitative activities. To prepare phys­ curricula based on the needs and priorities icians and therapists to train community of the community. health workers in disability prevention and rehabilitation, and to supervise their work, 12.95 In August I979, a three-week country-level training projects were interregional study tour took place in started in Argentina, Bolivia, Brazil, Chile, China, on maternal and child health care and Colombia, El Salvador, Guyana, Jamaica, family planning as part of community Mexico, Peru, and Venezuela. A meeting development, particularly in rural areas. of therapists involved in training pro­ It was followed in October by a study grammes was held for the English-speaking tour in which Chinese health workers countries of the Caribbean (Nassau, Octo­ visited Japan, Sri Lanka and the Philip- ber I978). THE WORK OF WHO, 1978---1979

Other types of training Brussels (I978) and attended by senior public health administrators and experts I2.99 To promote health services research from 2 I countries. A series of courses on in decision-making, a regional orientation the prevention and control of neurological course was organized for health adminis­ disorders and on psychosocial factors in trators and senior health workers (Alexan­ public health were held in schools of public January I979). dria, health, primarily for students from devel­ oping countries. I 2. Ioo In occupational health, there was a one-month international course for devel­ I2.I03 In the field of drug dependence oping countries (Sofia, I978) ; a third there were three workshops for public international course on environmental and health administrators and technical per­ occupational toxicology at the Institute of sonnel (one in Alexandria, I978; two in Occupational and Radiological Health, Thailand, I979) and a five-week course on Belgrade, a WHO collaborating centre the management of drug abuse problems (I979); and a six-week course on the (Hong Kong, I979) for participants from principles of industrial toxicology (Lodz, the South-East Asia, Eastern Mediterranean Poland, I979)· WHO also cooperated in and Western Pacific Regions. various national courses during the bien­ nium, among them a two-week orientation I2.I04 In the South-East Asia Region, course on toxicity of pesticides (Cairo, I 978), several countries (Bangladesh, Burma, a two-week course on occupational health India, Indonesia, Mongolia, Sri Lanka, methodology (Sao Paulo, Brazil, I979); and Thailand) now provide postgraduate and a six-week postgraduate course on training in psychiatry ; India, Indonesia, occupational health for physicians and Mongolia and Thailand also have post­ nurses (Manila, I978). graduate training programmes in the neuro­ sciences ; and India and Thailand provide specialist training for other health per­ I2.IOI In health edttcation, WHO con­ sonnel, such as nurses, social workers, and tinued to collaborate with many Member occupational therapists, who are called States in training health personnel or upon to deal with mental health matters. workers in other development sectors. For example, in the African Region, 34 I2.I05 During the biennium, a four­ health workers from ten African countries month training programme in epidemio­ received training in Nigeria ; in the logical psychiatry and the social aspects of European Region the first courses in health mental health was carried out consecutively, education in the German language were in six WHO collaborating centres and at started at the Academy of Public Health, headquarters, at which I7 professional Dusseldorf, Federal Republic of Germany ; mental health workers from developing in the Western Pacific Region, special train­ countries received training in advanced ing in health education is being given to research methods. Courses in biological intermediate-level health workers in Papua psychiatry, psychopharmacology, and the New Guinea. management of common neurological dis­ orders continued at the WHO collabor­ I2.I02 Training act1v1t1es in mental ating centres. health during the biennium included a workshop on psychosocial factors in health, I 2.106 A postgraduate training pro­ held at the WHO collaborating centre, gramme in psychological medicine was HEALTH MANPOWER DEVELOPMENT

started in Taif, Saudi Arabia, where man­ multidisciplinary trammg in epidemiology power is also being trained for mental and preventive ophthalmology. health facilities at the peripheral level of the health services. I 2. I I 3 Various courses in veterinary public health were offered to veterinarians I2.I07 In the Western Pacific Region in the Region of the Americas at the Pan work continued in Fiji, the Philippines American Zoonoses Center, Buenos Aires. and the Republic of Korea to develop They covered the production and control curricula in mental health for under­ of rabies vaccine, the planning of veterinary graduate and postgraduate medical edu­ health programmes, and brucellosis. In cation. Brazil, the Pan American Foot-and-Mouth Disease Center, Rio de Janeiro, collab­ I2.I08 In the Region of the Americas, orated with the School of Veterinary more than 5o national or international Medicine of the Federal University of courses in psychiatric nursing, alcoholism, Minas Gerais, Belo Horizonte, in offering and drug abuse control were given in postgraduate courses in epidemiology and I 7 countries. vital statistics.

I2.I09 During the biennium, WHO and I 2. I I4 For trammg in the prevention the International Council of Nurses and control of zoonoses and foodborne diseases reviewed the mental health component of at undergraduate and postgraduate level, nursing education in 2 5 countries with a an interregional seminar on the develop­ view to the exchange of experience and ment of manpower in veterinary public ideas on learning objectives, curricula, health (New Dehli, I978) and the fourth and teaching methods leading to the FAOfWHO expert consultation on veter­ revision of national programmes. inary education (Uppsala, Sweden, I978) recommended specific measures to strength­ I2.IIO WHO participated in many en both medical and veterinary curricula. national courses for malaria workers at the International postgraduate courses on food peripheral level. Two seminars were held microbiology for students from developing in India, one on applied field research in countries continued in the four training malaria and the other on the preparation centres in Europe participating in this pro­ of research proposals. gramme-in France, the Netherlands, the United Kingdom, and Berlin (West). How­ I 2. I I I Courses on sexuai!J transmitted ever, the trend is towards holding such diseases were held at national and regional courses in the developing countries them­ level in four Regions : Africa, the Americas, selves, and an intercountry workshop on South-East Asia and the Western Pacific; advanced microbiological methods in food it was emphasized that the control of such hygiene was held in Izatnagar (India) diseases should be a part of general health in I979· care. I 2. II 5 A particular effort was made to I 2. I I 2 A network of WHO collab­ organize a series of master's degree courses orating centres for the prevention of blindness in medical entomology and vector control in the is being established in all regions to conduct African and South-East Asia Regions. training and research and promote appro­ Courses were also organized on rodent priate activities. The centres will offer biology and control (Iraq), on urban THE WORK OF WHO, 1978-1979 mosquito control (Libyan Arab Jamahiriya), Israel, Kenya, Netherlands, and Switzer­ and on the aerial application of insecticides land, and also in Egypt and Portugal. against tsetse fly (Ivory Coast). A regional Courses on hybridoma technology were training centre for malaria and vector given in Brazil and Switzerland. biology control was established in Baghdad for the Eastern Mediterranean Region. I 2. I 20 In environmental health, the Regional Office for South-East Asia ran a I 2. I I6 As part ofits institution-strength­ course on monitoring of water quality ening activities, the Special Programme (I979) for participants from the reporting for Research and Training in Tropical stations that are part of the UNEP(WHO Diseases awards research training grants global environmental monitoring system. and grants to enable scientists to visit other A training workshop on monitoring of air institutions. During the biennium, more quality was held for participants from than I oo such grants were approved. French-speaking countries of the African Workshop, seminars or courses were organ­ and European Regions (Sofia, I978). ized on such subjects as research methods in tropical health, sensitivity of malarial I2.I2I To meet the need for manpower parasites to drugs, and biological control in water supply, sanitation and environ­ of vectors of disease. mental protection programmes in the Western Pacific Region, steps were taken I 2. I I 7 In the control of cardiovascular in I978 with a view to organizing a course diseases, WHO collaborated with the for sanitary inspectors at the Institute of Scientific Council on Epidemiology and Hygiene and Public Health, Manila. Prevention of the International Society and Federation of Cardiology in the latter's annual international teaching seminars I 2. I 22 The Institute of Public Health (Innsbruck, Austria, I 978 ; and Stirling, Engineering and Research was established United Kingdom, I979)· A three-week at Lahore, Pakistan, to train professional course on the prevention and control of sanitary engineering personnel. This is an such diseases, with emphasis on control addition to similar training centres already at the community level, was organized by operating in Alexandria (Egypt), Beirut, the Regional Office for the Western Pacific Khartoum, Shiraz (Iran) and Teheran. Region (Wellington, October I978). I2.I23 Personnel who can use and I 2. I I 8 WHO cooperated with the Inter­ maintain a health records rystem are often national Society of Radiographers and scarce. In the Eastern Mediterranean Radiological Technicians in conducting a Region, a working group (Alexandria, I978) survey on the training of radiology technicians proposed methods for training in the col­ throughout the world. The data received lection, recording, and reporting of from some 50 Member States showed that information. The group recommended training still varies greatly from country that WHO collaborating centres should to country and ranges from formal courses give this type of training and that simple to on-the-job training. self-instructional material should be pro­ duced for workers in primary health care. I2.II9 Training courses in immunology In the Western Pacific Region, national were given at the WHO immunology staff are being trained in the Philippines to research and training centres in Brazil, establish medical records systems. WHO

186 HEALTH MANPOWER DEVELOPMENT cooperated in producing manuals on the Special Programme for Research, Develop­ relevant procedures. ment and Research Training in Human Reproduction, will be found in Chapter 6, I2.I24 A training programme was paragraphs 6.25, 6.37, 6.50, and 6.63-6.70. undertaken in I978-I979 to familiarize statistical coders with the ninth revision of the International Classification of Teacher training Diseases. Courses were held in many countries in four Regions-the Americas, I 2. I 30 In an attempt to alleviate the South-East Asia, the Eastern Mediterranean, shortage of well-trained teachers for health and the Western Pacific-and over 300 workers in primary health care WHO people so far have been trained. (See also collaborated during the biennium with Chapter I3, paragraph I3.22.) Papua New Guinea, Sudan, Turkey, and the United Republic of Cameroon in I2.I25 In order to strengthen national establishing national centres that would health information systems, seminars were provide training in maternity and child organized for physicians, administrators health care and fami!J planning for teachers and other health personnel to emphasize and supervisors of community health the importance of collecting and analysing workers in rural areas. The six-week inter­ basic data and statistics (Pakistan and regional courses in fertility management Indonesia, I979)· and maternal and child health care, held twice a year for senior teachers from I 2.126 Statisticians from various developing countries, were continued. English- and French-speaking developing countries attended a course in health statistics at the centre for advanced training I 2. I 31 An interregional conference on in applied statistics for developing countries the teaching of statistics to medical under­ (Munich, Federal Republic of Germany, graduates, organized in conjunction with I979)· the International Epidemiological Associa­ tion and the Government of Pakistan I2.127 To meet the demand for per­ (Karachi, March I978), recommended that sonnel to produce and maintain orthotic workshops should be conducted for staff and prosthetic appliances, workshops were carrying out such teaching, and that more held in four countries of the African self-instructional material should be pre­ Region: Benin, Guinea-Bissau, Ivory Coast pared for undergraduates, and for medical and Upper Volta. WHO also collaborated and other health personnel. Workshops with the World Rehabilitation Fund in were subsequently held in Athens and organizing a three-week training course for Karachi to permit the exchange of teachers' orthotic and prosthetic technicians (Nairobi, experience, the discussion of programmes, I978). and the study of how modern educational principles and techniques can be applied I 2. I 28 The regional centre for main­ to the teaching/learning of statistics. tenance and repair of medical equipment, Cyprus, is now in operation and has trained I 3 students from eight countries in the I2.I32 An interregional workshop Eastern Mediterranean Region. cosponsored by the International Federa­ tion of Health Record Organizations was 12. I 29 Details of training under the held for teachers of medical records sciences fami!J health programme, including the (New Delhi, I979)· THE WORK OF WHO, 1978-1979

I2.IH A JOlnt WHO/International field trials in Colombia and Yemen in I 980 ; Dental Federation working group was a manual on nuclear medicine, published in established to define educational objectives Trombay (India) is being used to develop and develop curricula for all levels of dental a WHO manual on basic nuclear medicine. personnel. A manual, Common Oral Diseases, Prevention and Emergenry Care: I 2.13 5 WHO collaborated with Egypt A Manual for Teachers, was prepared for and Nigeria in producing training brochures the teachers of health personnel working and slides in English and French on vector in oral primary health care and is being biology and control. The brochure Multilevel field-tested in Bangladesh, Malawi and Course on the Safe Use of Pesticides a11d on the Mozambique. Diagnosis and Treatment of Pesticide Poisoning will be used in regional and national Teaching/learning materials training courses.

I2.I34 Many WHO programmes are I2.136 The Expanded Programme on now preparing training material to facilitate Immunization supported training in cold­ the teaching/learning process. In radiation chain management by means of a series of medicine, manuals prepared for operators of visual aids, including slides, posters and basic radiological machines were ready for simple publicity materials.

I88 Chapter 13

Health Information

I3.I THE KEY organizational devel­ were to cooperate with Member coun­ opment at headquarters in I979 tries in developing the managerial and was the linking of the pro­ technical information support required for grammes of health statistics, health and planning, executing and evaluating national biomedical information, health information health programmes, and more particularly : of the public, and information systems by (a) developing or strengthening health an interdivisional coordinating committee information systems and services, includ­ under the leadership of the Deputy ing health statistics, as an integral com­ Director-General. This helped to clarify ponent of health services; (b) applying the problems of information transfer con­ statistical and research methodology to fronting the Organization and enabled specific health studies; (c) promoting the responsibility to be more precisely allocated development and training of all categories among the four programmes concerned.1 of health personnel in epidemiology, health statistics, and operational research ; (d) I 3. z A parallel reorganization took developing or improving statistical stan­ place in the Regional Offices for the dards, definitions, nomenclature, classifi­ Americas and for Europe ; other regional cation and procedures, including an ap­ offices were also studying suitable ways propriate methodology for the lay report­ of responding to the demands of infor­ ing of morbidity and mortality ; and (e) mation transfer. Particular emphasis is collating, analysing and disseminating being given to strengthening the organ­ information on the health situation of izational and administrative links between Member States. headquarters and the regional offices and in this way determining as accurately as I 3·4 The approach was based on : possible the information needs of Member States and how best to meet them. (I) formulation of socially relevant and operationally realistic health information policies; Health statistics (z) promotion of national capacity to I 3. 3 The objectives of the health stat­ collect relevant data and convert them istics programme during the biennium into timely information for health man­ agement at all levels ; 1 The first three programmes are dealt with in the present chapter, the information systems programme (3) use of the systems analysis approach in Chapter 2 (paragraphs 2.22-2.27 and 2.46-2.61). and promotion of a userfproducer dia- THE WORK OF WHO, 1978--1979

logue to develop purpose-oriented health knowledge and skills, both during their statistics services as part of national studies and in their future professions. health information systems and services ; Hence, the training of teachers became a (4) development of simplified method­ pressing concern and a start was made ology for the collection and use of in the school of medicine, which, tradi­ statistics at the primary health care tionally, has shown the greatest reluctance level; to teach statistics. (5) training for teachers of health stat­ I 3. 7 An interregional conference on istics ; teaching statistics to medical undergradu­ 1 2 (6) basic research in health statistics ates • was organized in I 978, jointly carried out through collaborating cen­ with the Government of Pakistan and the tres, research institutions, and other International Epidemiological Association competent national and international (see also Chapter 12, paragraph IZ.I3I), to bodies; discuss and answer five important ques­ (7) collaboration with other organ­ tions: why, what, how, when, and by izations of the United Nations system whom should statistics be taught to medical with a view to a coherent approach students ? The answers given were to statistical concepts, principles and intended to encourage teachers to demon­ standards, and joint action in support strate to students the relevance of statistical of socioeconomic development. knowledge to all branches of medicine, thus bringing about a decisive change in Development of health statistical services the students' attitude to the subject. It is hoped that the conference's recommen­ I 3. 5 The challenge to countries to dations will also motivate faculty members mobilize all their health manpower other than teachers of statistics (e.g., resources for an attack on major health teachers of clinical subjects) to introduce problems-implicit in resolution WHA29.72 statistical principles as applied to medicine of the Twenty-ninth World Health into their own lectures. Assembly (I976)-brought education and training to the forefront of the programme I 3. 8 Guidelines for the practical organ­ for development of health statistical ser­ ization of national or regional workshops vices. A comprehensive campaign was for teachers of statistics, and for other launched to equip both health statistics members of the medical faculty, were workers and health staff in general with established by a working group on the the statistical competence they need when subject. A first national workshop of this recording, analysing, reporting and inter­ kind was organized in I979 to work out preting health data. The strengthening a systematic approach to the teaching and of health statistics manpower at all levels learning of health statistics in the medical is a prerequisite for strengthening the undergraduate course. whole health information system, and thus 1 raising the quality of health care delivery. Government of Pakistan/WHO/International Epi­ demiological Association. The sl/ccessful teaching of statistics to every medical student. Inte"egional conference I 3.6 To make health statistics teaching on teaching statistics to medical undergraduates. Karachi, as cost-effective as possible, optimum 1978. teaching methods are required. The 2 Lowe, C. R. & Lwanga, S. K. Health statistics: teacher must be thoroughly acquainted A manual for teachers of medical students. 1978, Oxford University Press (Handbooks sponsored by the lEA with the students' actual needs in statistical and WHO, No. 1). HEALTH INFORMATION

I3·9 An extensive training programme information needs. WHO has repeatedly was also started in medical and health recommended that the forum for such a records. In previous years the emphasis dialogue should be an adequate body at had been on improvement of hospital national level, such as the national com­ medical records. During the period under mittee on vital and health statistics or an review, work was mainly directed towards equivalent national coordinating body. primary health care records. For help to be This recommendation takes on a new given to the underserved populations of significance in the reorientation of national the world, as required by the Declaration health information systems, since close of Alma-Ata, information must be available collaboration with and coordination of the on their health and environmental con­ various levels generating health infor­ ditions ; and to create a reliable infor­ mation are among the major terms of mation base, primary health care personnel reference of such committees. must receive adequate statistical training. These matters were discussed by another I 3. I 2 A consultative meeting on national health information systems was working group (see also Chapter I2, para­ convened in December I 978 by the graph 12.I23). Regional Office for South-East Asia to I3.Io Training of medical records per­ discuss the purpose and ways of developing sonnel was also promoted in the various national health information systems in WHO regions. For example, in one Member countries and stimulate their country of the Western Pacific Region, interest. work was undertaken to link the medical I 3. I 3 A seminar on the same subject records system with the hospital manage­ was organized by the Regional Office for ment information system. Contractual the Americas early in I979, followed in agreements for collaborative projects in November of the same year by an inter­ health and medical records were concluded regional consultation in Costa Rica, in or renewed with public health institutes both of which producers and users of in the European and Eastern Mediter­ health information participated. The ranean Regions, with a view to designing purpose of the meetings was to define in and testing health records systems for detail the principles and structure of a use at community level. national health information system and its components, and to define its strategy. I 3. I I The need for national health infor­ mation .rystems as a basis for national health I 3. I 4 Seminars for physicians, admin­ planning, management and evaluation is istrators and other health personnel were urgent, and was emphasized by the Health organized in countries of the Eastern Assembly in resolution WHA3 1.20. Health Mediterranean Region, to identify health statistics play a vital role in such systems information needs and promote better since they provide the primary information collection of basic data, proper use of for each part of the health sector. Yet much statistics, and integration of the health of the statistical data at present collected statistical system into the health services is not fully utilized by the decision-makers. administration. These seminars can be A dialogue between providers and users considered as pilot programmes for training of health statistical information is therefore 11sers of health data in the analysis of health needed so that the provider of data can statistical systems and the assessment of help the user to formulate clearly his information needs. THE WORK OF WHO, 1978-1979

Health statistical methodology strategies, evaluation of results, and methodology of public health forecasting. I 3. I 5 As in the past, the support An extensive review was made of the services in health statistical methodology potentialities for improving the application for WHO-assisted programmes provided of statistical techniques to primary health (I) the statistical and mathematical basis care, including family health, in developing for planning and executing projects and countries. for analysing and evaluating field data ; ( 2) the methodological basis for operational I 3. I 8 Collaboration continued with the research, systems analysis, and mathematical International Institute of Applied Systems modelling as applied to epidemiological Analysis, Vienna, and the close contact investigations and the improvement of established with several intergovernmental health delivery systems ; and (3) the and nongovernmental organizations methodological basis for the use of com­ working in the field of informatics and puter facilities in the Organization's medi­ medical computing was maintained. In cal, epidemiological and health service particular, an updated review of computer work. applications in medicine was prepared. I 3. I 9 National capacity for providing I 3. I 6 The transfer to developing coun­ methodological support of this type, tries, in an appropriate form, of tech­ especially in developing countries, was nological advances in applied statistics, promoted in several regions. Cooperation operational research, systems analysis and included the award of fellowships and medical computing, received particular special training courses for epidemiologists emphasis. To this end, the volume of and public health workers. basic statistical processing by WHO itself is being scaled down, such processing being gradually transferred to country International classification of diseases level. WHO increasingly assumed a I3.2o The I978-I979 biennium was coordinating and interpretative role, the somewhat of a watershed in the programme effectiveness of its action being increased for classification and nomenclature of by a "multiplier effect", i.e., by developing diseases. Not only did it mark the programmes to coordinate the method­ beginning of a new decennial cycle for ological work that will be carried out at the revision of the International Classifi­ country level by qualified professionals, cation of Diseases, it was also the period at the same time promoting national of the first tangible results of the pro­ capabilities for providing this support. gramme's reorientation.

I 3. I 7 The Organization's method­ I3.2I The publications programme ological resources could thus be con­ related to the Ninth Revision of the centrated in depth on a small number of International Classification of Diseases high-priority programmes-but even here (ICD-9) was completed. In addition to with the object of transferring much of the two volumes of the Classification the work to country level as soon as proper, 1 two supplementary classifications suitable methods have been established. Attention focused on the operational prob­ 1 World Health Organization. Manual of the inter­ lems of health delivery systems, allocation national statistical classification of diseases, injuries and causes of death, 1975 revision, Volume 1, Geneva, 1977; of resources, selection of intervention Volume 2 (Alphabetical index), Geneva, 1978. HEALTH INFORMATION were published by WHO for the first of health information, 4 produced in re­ time : the International Classification of sponse to resolution WHA29. 3 5 and field­ Procedures in Medicine, 1 and the Inter­ tested in the South-East Asia Region. national Classification of Impairments, Its purpose is to assist countries where Disabilities and Handicaps. 2 there are few physicians to obtain useful morbidity and mortality statistics from I 3.22 In conjunction with the regional reports made by auxiliary or lay personnel. offices, a large training programme was Since local circumstances differ greatly, undertaken to familiarize coders with the the booklet was written as a "do-it­ provisions of the Ninth Revision. Courses yourself" guide to the setting-up of a were held in the Regions of the Americas system for such reporting. Training (Bahamas, Barbados, Brazil, Canada, Co­ material in the form of slides was also lombia, Cuba, Jamaica, Mexico, Peru, prepared. The introduction of lay report­ and the United States of America), South­ ing was studied in countries of the Region East Asia (Burma, India, Indonesia, and of the Americas and the South-East Asia Thailand), Europe (Union of Soviet Social­ and Western Pacific Regions. ist Republics), the Eastern Mediterranean I3.24 The heads of WHO centres for (Bahrain), and the Western Pacific (Fiji, classification of diseases met twice, mainly Hong Kong, Japan, New Zealand, to evaluate alternative models for the form Philippines, and Republic of Korea). Many and structure of the Tenth Revision of of these courses were also attended by the International Classification. Their participants from neighbouring countries. views were transmitted to a meeting on In all, over 300 persons were trained, for classification of diseases (Taormina, Italy, the most part coding supervisors or heads of coding units who will in turn run November I979), the first of the new revision cycle, which recommended that similar courses for individual coders in the overall structure of the International their own countries. Classification should not be radically I 3. 2 3 The increase in technical coop­ changed in the Tenth Revision. The basic eration with developing countries was classification, however, should be greatly represented by two other publications. simplified so as to be usable in many The first was an alphabetical index to the more countries than at present ; more Basic Tabulation List of ICD-9, 3 which complex modules could be built in to the is intended to help countries that lack the basic core, for use where greater detail resources to code in accordance with the or sophistication was required. The long and complex Detailed List but are meeting also recommended that lay­ able to use this shorter and simpler list. reporting methods should continue to be The second was a booklet on lay reporting developed.

Dissemination of statzstical information 1 World Health Organization. International classi­ fication ofprocedures in medicine, Volumes I and 2. Geneva, I 3·25 The Sixth Report on the World 1978. 6 2 World Health Organization. International classi­ Health Situation, covering the years fication of impairments, disabilities, and handicaps. A manual of classification relating to the consequences of dis­ 4 World Health Organization. Lay reporting 1!, esases. Geneva, 1980. health information. Geneva, 1978. 3 World Health Organization. International classi­ 5 World Health Organization. Sixth report on the fication of diseases, ninth edition : Basic tab11lation list with world health situation, I9JJ-I971· Part I, Global analysis; alphabetical index. Geneva, 1978. Part 2, Review by country and area. Geneva, 198o THE WORK OF WHO, 1978-1979

I973-I977, was prepared in I979 in included mental health, cancer, and family accordance with the decision by the health. Heatlh Assembly (resolution WHA29.22). I3.27 A report on social and biological The difficulties encountered point to the effects on perinatal mortality 4 was pub­ need for further effort both to improve lished in I979 in collaboration with the the report and to adapt it to the new Government of Hungary ; Volume I gives international socioeconomic order by the results of an international collaborative reflecting trends in health policy and health study, Volume 2 contains statistical tables action, and the results obtained. The first of data collected during the study, and volume of the report describes global Volume 3 (in preparation) will comprise health problems and the measures taken an in-depth analysis of the data. Other to solve them and indicates the success publications in I 978 included Health and or failure of such measures at national, the Fa!Jii(y, 5 and a Life Table and Mortaliry regional and international level ; the second Ana(ysis. 6 The report of an ad hoc survey volume reviews the situation country by of infant and early childhood mortality country. The preparation of the report in relation to fertility patterns, carried out entailed not only the international collec­ in Greater Kabul in I972-I975, was also tion of health statistics but also the calcu­ published. 7 lation of health indicators, and the report itself should thus provide feedback for I;.28 The WHOfiARC Expert Com­ use by Member countries. mittee on Cancer Statistics (Madrid, I978) recommended inter alia that studies should I 3. 26 Health statistical information be made of the problems encountered in continued to be disseminated through a setting up data bases for the planning and number of other publications, chief among management of cancer control programmes them being the World Health Statistics in developing countries. It also recom­ 1 2 Annual. • In I 979, the number of pages mended the standardization of method­ of the Annual was reduced for reasons of ology, and of reporting the results of economy, so that whereas Volume I (dealing studies on survival experience of cancer with vital statistics and causes of death) con­ patients and their quality of life after tinues to appear annually, Volumes II treatment. and III (dealing respectively with infectious diseases and with health personnel and I3.29 The project for monitoring the hospital establishments) are now published requirements of countries as regards mental in alternate years. In the World Health health statistics continued, and by the end Statistics Quarter(y,S the tables on current of I 979 all the participating countries had data were discontinued in order to give submitted their reports. more place to analytical studies on special subjects of public health interest ; these 'World Health Organization. A WHO report on social and biological effects on perinatal mortality. Budapest, I978. 1 World Health Organization. World Health Stat­ 5 World Health Organization. Health and the family. istics Annual, I9J8. Volume I: Vital statistics and causes Studies on the demography of family life cycles and their of death, Geneva, I978; Volume II: Infectious diseases: health implications. Geneva, I 978. Cases and deaths, Geneva, I 978 ; and Volume I I I: 6 Chin Long Chiang. Life table and mortality analysis. Health personnel and hospital establishments, Geneva, I979· Geneva, World Health Organization, I978. (Out of 2 World Health Organization. World Health Stat­ print ; revision in preparation.) istics Annual, I979· Vital statistics and causes of death, 7 World Health Organization. Infant and early Geneva, I979· Infectious diseases: Cases, Geneva, 1979. childhood mortality in relation to fertility patterns. Alexan­ 3 Formerly the World Health Statistics Report. dria, I978. HEALTH~INFORMATION

Health and biomedical information I 3. 3 2 Another matter studied during the biennium was how to ensure easy and Health literature serz;ices economical retrieval of the information contained in the approximately 8ooo pub­ I3.30 A major new 1rut1at1ve is the lications and documents issued annually work being done to develop a health­ by headquarters and the regional offices. related information systems (HERIS), Plans for a WHO Document Information particularly for developing countries, to System (WHODIS) were prepared by fill an identified gap in the coverage of headquarters and the regional offices in ex1stmg information systems such as close collaboration and were submitted MEDLARSJMEDLINE, Excerpta Medica, to potential users in various forums for and other bibliographical retrieval systems comment ; a feasibility study is also in that place primary emphasis on clinical progress. and experimental medicine. This inter­ national data bank will be focused on I 3. 3 3 Considerable work was done to public health problems, particularly on the strengthen regional and national health planning, management and evaluation of literature services. Because of the diversity health services. It will monitor journals of conditions in the different regions, the from developing countries that are not at approach taken has been equally varied. present indexed and will draw on the large In the Region of the Americas, for example, mass of highly relevant but difficult-to­ the well-estableshed facilities of BIREME, retrieve information in the "fugitive lit­ the regional medical library mentioned erature", e.g., government reports, insti­ above, serve as a focal point for the tutional studies, etc. In addition it will development of national and regional seek to tap sources of information in networks of health information centres developing countries, with a view to and libraries ; in the South-East Asia making such information available­ Region, priority was given to strengthening within the context of technical assistance national networks; while in the Western among developing countries-to other Pacific Region, considerable headway was countries facing similar problems. made in developing regional networks.

I 3. 3 I The plans for HERIS received WHO publicatioNs the preliminary endorsement of all re­ gional offices and of the Subcommittee I3·34 Just as HERIS and WHODIS on Information of the global Advisory are intended to complement existing infor­ Committee on Medical Research. The mation services, the developmental work concept was also endorsed by the Inter­ that has gone into World Health Forum: national Development Research Centre An international journal of health development in Canada and the National Health Planning represents an attempt to fill a gap not Information Centre in the United States only in the range of WHO publications of America. Consideration is being given and periodicals but also in the coverage to the possibility of integrating some of of national and international medical and the data bases of these two centres with public health journals. Most existing that of the Regional Library of Medicine journals are specialized in character and (BIREME) in Brazil and incorporating national in outlook. Thus there is at them, under WHO sponsorship, into the present no single journal or group of HERIS system. journals to which the health planner and THE WORK OF WHO, 1978-1979

policy maker, the health administrator 13.37 For the Bulletin of the World and educator, or public health workers Health Organization, the biennium was a in general can turn for reliable, up-to-date period of important reorientation in con­ and practical information on the range of tent, to enable it to contribute more problems confronting them and their directly to the transfer of the kind of counterparts in other Member States, information needed for the attainment of particularly in developing countries. A health for all by the year 2000. Beginning feasibility study was carried out to deter­ with the January I978 issue, a series of mine whether WHO could meet this need "Update" articles was introduced that and, even more important, in so doing provide concise and authoritative accounts stimulate new thinking by providing a on the current state of the art in a wide platform for the exchange of ideas. range of medical and public health matters. Particular emphasis is given to infor­ 13.35 To provide an actual example mation of immediate utility in health of what this new journal might contain, development, thus providing busy re­ a trial issue was prepared and given wide search workers and health managers with circulation within the Secretariat, both at a summary of what they need to know headquarters and in the regions. The on a particular subject, together with response was very favourable and many selected references to a few key works useful comments and suggestions were they should consult for additional infor­ received. As a result an improved trial mation. This innovation was introduced issue was prepared for circulation to several without appreciably diluting the scientific thousand selected recipients, along with quality of the journal and was well received. a questionnaire the results of which will form part of the Director-General's report I3.38 To make sure that the WHO on the proposed Forum to the Executive Chronicle was doing its job of keeping Board. readers informed of WHO activities and I 3. 36 In an intensified effort to deter­ publications, a questionnaire was circulated mine the information needs of Member to the more than 20 ooo recipients of the States and how best and most economi­ four language editions. On the basis of cally to respond to them, a comprehensive comments and suggestions received, the Secretariat-wide survey was conducted on content of the Chronicle was adapted to the reorientation of WHO's programme conform more closely to the expressed of publications and documentation. Its wishes of its readers. An air-mail edition aim was to elicit specific suggestions for was introduced to accelerate delivery to improvements. The results have been readers outside Europe. analysed and will be submitted to Member States in each region in order to obtain I 3. 39 For the non-periodical technical a representative view of what changes publications, such as the Pttblic Health are desirable in the type and scope of Papers, WHO Offset Publications and the existing publications and also to establish nonserial publications, the selection of a channel for a continuing dialogue on titles was measured against increasingly these matters. This was the first time in strict criteria, namely the relevance of the the life of the Organization that such a material to the needs of Member States, thorough study of the total publications in particular the developing countries, programme, both at headquarters and in and the contribution that it was likely the regions, was undertaken. to make to the attainment of health for HEALTH INFORMATION all by the year 2000. Among the more series, PHblic Health in EHrope and Regional important books published 1 during the Pt~blications, European Series, was expanded biennium are Alma-Ata IjJ8: Primary to include a new series entitled EURO Health Care; PHblications of the World Reports and Studies, in which will be pub­ Health Organization: Bibliograpf?y, IjJ}-IjJJ; lished the final reports of meetings (hitherto Field gttide to the detection and control of issued only as documents) and other xerophthalmia; Formulating strategies for material of lasting value. (See also Chap­ health for all fry the year 2000 ; A growth ter I5, paragraphs I5-l33-I5-I34)· chart for international use in maternal and child health; The management of nHtritional I 3·43 In the Region of the Americas, emergencies in large populations; THberc11losis­ PAHO's large and long-established pub­ Case finding and chemotherapy : qHestions and lications programme benefited from new answers; World directory of medical schools, institutional arrangements that will permit fifth edition; International Pharmacopoeia, it to respond more effectively to priority t~1ird edition, Vol111ne I; and Pf?ysician and requirements and facilitate close coordi­ nurse migration. Poverty, development, and nation between PAHO and WHO pub­ hgalth policy was published in the Public lications. The most important of these Health Papers, and Risk approach for arrangements was the establishment of maternal and child health care in the WHO the PAHO/WHO Publications and Docu­ Offset PublicatioJts. mentation Service in Mexico ; this service has already taken over the production of I3.40 In collaboration with UNEP, a the Boletin de la Ojicina Sanitaria Pan­ further eight volumes of the Environmental americana and the translation into Spanish Health Criteria were issued, dealing inter of WHO technical publications. alia with DDT, mycotoxins and ultra­ I 3·44 Elsewhere, in the African, South­ violet radiation (see Chapter I I, para­ East Asia and Eastern Mediterranean graphs II.3I, II.32, and II.35)· Regions, regional publications programmes I3-4I During the biennium 26 numbers were being developed or expanded. To were published in the Technical Report ensure that all regional publications reach Series, covering such subjects as gonorrhoea, the broadest possible audience, head­ periodontal diseases, traditional medicine, quarters both publicizes them and handles induced abortion, antibiotic-resistant en­ their distribution outside the originating terobacteria, parasitic zoonoses, arterial region. hypertension, essential drugs, financing of health services, training and utilization I 3·4 5 Information on publications of the International Agency for Research on of auxiliary health personnel, and control Cancer will be found in Chapter IO (para­ of the smoking epidemic. graphs IO.I7, 10.I8, 10.32, and 10.36). I 3.42 Another major development in I 3.46 In a period of inflation, as was the Organization's publishing programme was the marked trend towards regional­ the I978-I979 biennium, an attempt was made to contain printing costs by using ization. The strong programme of the modern technology and by printing in Regional Office for Europe, with its two countries where prices are rising less rapidly. In addition, academic and other 1 Further information will be found in World Health publishers were encouraged to take over Organization publications. Catalogue, I947-I919· Geneva, 1980. works arising out of WHO programmes

I97 THE WORK OF WHO, 1978-1979

which, though useful, do not meet the and effective access to all necessary infor­ strict criteria referred to above or cannot mation. WHO is endeavouring to mobilize be fitted into the limited budget for the experience and information available editing, translation and printing. in the industrialized countries in such a way as to benefit the developing countries I 3·4 7 There was a marked increase that seek to cooperate with each other in the number of titles translated into and with WHO in this vital sector of health languages other than WHO's six working policy. Efforts are under way to identify languages and published by governments, institutional and individual expertise in institutes, and commercial firms. two of WHO's regions, and to determine needs in at least two other regions. Health legislation I 3. 5o The current primary mechanism I 3.48 Both at headquarters and in the for disseminating such information, the regional offices WHO made a determined International Digest of Health Legislation effort during the biennium to compile (of which eight issues were published essential information on health legislation during the biennium), is being revitalized policies and needs at national level so as by the inclusion of a much higher pro­ to create the necessary framework for the portion of analytical articles and surveys full implementation of resolution WHA30.44 elucidating the background to new and (I977)-a resolution that had stimulated revised legislation, the framework within a complete rethinking of the approach which such legislation operates, and hitherto taken in the health legislation any obstacles encountered 1n its programme and led to intensive consul­ implementation. tations with many Member States (a questionnaire was despatched to all Member I 3. 5 I The Digest forms only one link States to ascertain their real needs and in a worldwide information network whose expectations in this sector). The timing effective functioning largely depends on of this process coincided with the recog­ the willingness of Member States to share nition by the Alma-Ata Conference that information and experience with one reforms in health legislation may well be another, not merely at meetings-such needed in some countries if the primary as the WHO-supported meeting on tech­ health care approach is to be effectively nical cooperation among the ASEAN implemented. Indeed, there is increasing countries on drug legislation, evaluation evidence that obsolete health legislation and quality assurance (Jakarta, November constitutes a veritable obstacle to the I979), and the meeting in the European full realization of the new health doctrines Region of the working group on legis­ that have been collectively endorsed by lation concerning nursing/midwifery ser­ WHO's Member States. In other contexts, vices and education (Hamburg, Federal the absence of appropriate legislation has Republic of Germany, December I979)­ been shown to constitute a menace, not but also through direct bilateral and only to public health but also to the quality multilateral links. of life, whether in the home, the place of work, or the public thoroughfare. Technical terminology I 3·49 The technical cooperation pro­ I 3. 52 The need for standardized ter­ grammes in health legislation now being minology to permit clear and unambiguous devised will of course depend on rapid health and biomedical communication has HEALTH INFORMATION continued to increase. Accordingly, a been continued. More publicity leaflets study was undertaken of ways in which on individual subjects were produced and the standardization of terminology could distributed, and the results have justified be rationalized, speeded up, and better this approach. Every opportunity was coordinated. The possibility of estab­ taken during the biennium to exhibit lishing a central terminology bank that WHO publications at international or would serve the needs of Member States, national conferences and at book fairs. regional offices, and technical and language staff at headquarters by providing an I 3. 55 Sales revenue increased sub­ instantly accessible source of multilingual stantially: it amounted to US$ 2 342 278 information, constantly updated, was being in I978 and US$ 2 728 884 in I979, as investigated at the end of I979· against US$ I 856 9I2 in I977· The increase over a longer term can be judged I3·53 WHO played a major role in by the sales in I 97 2, which realized a the joint CIOMSfWHO project on an total of only US$ 55 9 70 5. international nomenclature of diseases that is being carried out in accordance with resolution WHA29·35· The basic purpose Health information of the public of this project is to develop a single standardized name for every disease, to­ I3.56 The I978-I979 biennium was gether with an extensive cross-reference list a period of reappraisal and redirection of of synonyms. It will be an invaluable the programmes of public information. aid to communication between health The importance of "informed opinion and workers throughout the world and to active cooperation on the part of the public" information retrieval. One volume (dis­ in improving health, as recognized in the eases of the lower respiratory system) preamble of WHO's Constitution, was was completed and published during the again emphasized in the Declaration of 1 biennium. The preparation of several Alma-Ata, which stressed that primary others (communicable diseases, cardio­ health care required maximum community vascular and cerebrovascular diseases, and individual participation, sustained by gastrointestinal diseases, diseases of the an informed public opinion. blood and haemopoietic organs, and neuro­ logical disorders) was under way, with a I 3. 57 The recognition that much of view to publication during I 980-I 98 r. the burden of ill health can be lifted by changing individual and collective attitudes Distribution and sales and behaviour patterns challenged the traditional approach to public information I 3. 54 The last biennial report men­ work. A better coordinated, more dynamic tioned the new sales promotion measures approach was adopted to mobilize public for bringing WHO publications to the opinion in support of the objectives of attention of widely varied groups of WHO and Member States ; promote greater potential readers throughout the world. consciousness of the individual's role in These have proved successful and have maintaining his own health ; and cooperate with Member States and intergovern­ 1 Council for International Organizations of Medical mental and nongovernmental organizations Sciences. International nomenclature of diseases, Volume I I I. in introducing health information and Diseases of the lower respiratory tract, first edition. Geneva, 1 979· education programmes for the public.

I99 THE WORK OF WHO, 1978-1979

I3.58 Starting in I978, a major public reporting of health development issues by information programme was organized journalists and broadcasters. A network of with UNICEF to create greater public development-oriented journalists was estab­ awareness of the primary health care lished. As evidence of their interest, in process and support governments in pro­ I 978 French-language radio and tele­ moting it. Journalists and broadcasters vision stations in Africa, Canada, and were recognized as strong allies in this European countries produced some 20 work, and seminars on their role as agents radio and television programmes on pri­ of social change were organized in Alex­ mary health care themes. WHO's own andria, Brazzaville, London, Manila, New monthly I 5-minute radio broadcast in Delhi, and several other centres. The English, French and Spanish covered urgent need for information material that topical and newsworthy items, with em­ could be used by governments and non­ phasis on the primary health care approach. governmental organizations in support of I 3.6I World Health magazine, appearing the new approach to health care inspired in nine languages, increasingly stressed the production of four documentary films the role of health as a lever for social and in a series entitled "Health for all-Aspects economic development. Special issues of primary health care". The series were devoted to the subjects : technical depicts the primary health care approach cooperation among developing countries ; in Finland, Mexico, Mozambique, and primary health care ; justice in health ; Viet Nam. Financial assistance for the and the attainment of health for all by series was provided by DANIDA and the the year 2ooo. World Council of Churches. I 3.62 At its thirty-third session, the I 3. 59 Two essential elements of pri­ United Nations General Assembly em­ mary health care were illustrated in the phasized the need for greater coordination global and regional information campaigns within the United Nations system in of World Health Day (7 April of each public information activities and the re­ year). The I978 campaign, with the quirement that assistance should be given theme "Down with high blood pressure", to Member States in developing their stressed each person's capacity to avoid mass communication systems. During the or control hypertension. In I 979, the biennium WHO took an active part in theme "A healthy child, a sure future" a number of United Nations information emphasized that a greater investment in projects, including work on a supplement the health of mother and child is a vital in major world newspapers on points at component of primary health care. issue between developed and developing countries, and support to Development I3.6o Through the work of public Forttm, the tabloid newspaper of the information services in Geneva, and those United Nations system. United Nations in regional offices and at the United information centres provided valuable Nations in New York, attempts were made assistance in disseminating WHO films to foster more objective and knowledgeable and publications.

200 Chapter 14

Constitutional} Legal and Administrative Developments

Constitutional and legal matters I4·3 At the sixty-fourth session of the Executive Board (May I979) a member I4.I DURING THE BIENNIUM raised the question of whether the member­ I978-I979 two new Members, ship of the Executive Board could not, Djibouti and Seychelles, joined by a further amendment to Articles 24 the Organization by depositing formal and 2 5, be increased to 32, each member instruments of acceptance of the WHO serving for four instead of three years. Constitution following their admission to The Director-General has prepared a re­ the United Nations, as provided for in port on this question, for submission Articles 4 and 79 of that Constitution. to the Executive Board at its sixty­ It may be expected that, as in the past, fifth session (January I98o). Other con­ other newly independent States will rap­ stitutional questions may also result from idly join the Organization, thus maintaining the study on WHO's structures in the light the universality that is vital to the fulfilment of its functions. 2 of its objectives. A list of Members (at present I 52) and Associate Members (at I4·4 No instrument of acceptance was present two 1) is given in Annex I. deposited during the biennium for the amendment to Article 7 of the Constitu­ I4.2 The amendments to Articles 24 tion, adopted by the Eighteenth World and z 5 of the Constitution, which had been Health Assembly on zo May I965 ; the adopted in I976 by the Twenty-ninth number of acceptances received thus re­ World Health Assembly and which provide mains at 52. for an increase of the membership of the Executive Board from 30 to 3I, were I4·5 An amendment to Article 74, accepted by 22 Member States during the including an Arabic version of the Consti­ biennium I978-I979, bringing the total tution among the authentic texts, was number of instruments of acceptance so adopted on I8 May I978 by the Thirty­ far deposited to 40; a further 6z accept­ first World Health Assembly. By the end ances were still required for the entry­ of I979 it had received seven acceptances. into-force of the amendments, which under Article 7 3 of the Constitution must be I4.6 On II September I979 China accepted by two-thirds of the Members. acceded to the Convention on the Privi­ leges and Immunities of the Specialized 1 The associate membership of one of these, Southern 2 Rhodesia, was regarded as being in suspense. See Chapter I, paragraph r. I o.

20I THE WORK OF WHO, 1978-1979

Agencies and Annex VII thereof, which took as its starting-point the studies and relates specifically to the World Health first drafts prepared in I976 and I977 by Organization. The total number of WHO at the request on UNEP. It reached Members bound by the Convention has agreement on all the substantive issues in thus risen to 8 5. the draft, which aims at the control of pollution from industrial waste, municipal I4.7 Basic agreements on technical ad­ sewage, or agricultural pesticides and ferti­ visory cooperation were concluded during lizers. The final adoption and signature of the biennium with Cuba, Portugal, the the Protocol is scheduled to take place Solomon Islands, and Tuvalu ; other bila­ in I98o in Athens. teral agreements were concluded during the same period with China, Malaysia and I4.I I Problems relating to patent rights the Philippines. and the protection of the public sector with regard to inventions resulting from I4.8 The Regional Committee for Eu­ cooperation between WHO and research rope at its twenty-ninth session (September institutions or industry have become in­ I979) discussed the role of the Regional creasingly acute in several major pro­ Committee in the selection of Members grammes, in particular the Special Pro­ entitled to designate a person to serve on gramme of Research, Development and the Executive Board. Representatives of Research Training in Human Reproduction European Member States were not in and the Special Programme for Research favour of the proposal for a system of and Training in Tropical Diseases. It was rotation according to a geographical group­ therefore decided that a study outlining ing or by alphabetical order, and preferred the issues involved (including a comparative to leave the possibility of selection open as survey of the practices of other international hitherto. However, the Regional Director organizations and major national institu­ was requested to make the necessary tions) and the policy options open to the arrangements to allow Member States of Organization should be submitted to the the Region to reach a consensus at a session Thirty-fourth World Health Assembly. of the Regional Committee before or The capacity of the Legal Division to during each World Health Assembly. service technical programmes on an Organ­ ization-wide basis in this field will be I4·9 The Regional Committee for the strengthened. Western Pacific at its thirtieth session (October I979) reviewed the procedures for the nomination of candidates for the Administration 1 post of Regional Director and amended Rule 5 I of its Rules of Procedure. Establishment

I4,Io Under the auspices of UNEP, I4.I2 On 30 November I979, the total an intergovernmental meeting of legal and staff (excluding staff of the Pan American technical experts from most of the Medi­ Health Organization) was 4378 as com­ terranean governments was held in June pared with 4226 on 30 November I977 1979 at WHO headquarters to consider and 4275 on 30 November I978-an further the draft Protocol for the Protection increase of approximately I. I 5 % between of the Mediterranean Sea against Pollution 1 Budgetary and financial data are presented separately from Land-based Sources. The meeting in the annual financial reports.

202 CONSTITUTIONAL, LEGAL AND ADMINISTRATIVE DEVELOPMENTS

I977 and I978 and of 2.4% between I978 service, and covers such subjects as budget and I979· The posts accounting for the procedures, recruitment and personnel increase are to be found in the general administration, supply services, travel, con­ service category, particularly among pro­ ference services and organization of ject staff: the number of professional and meetings. higher graded staff decreased from I 707 I4.I7 Courses in the recognized official in November I977 to I63o in October I979· languages were organized at headquarters and in the regional offices. Staff development and training Office accommodation I4.I3 Staff development and tralmng activities in the regional offices continued I4.I8 The construction of an annex to to expand. In four regional offices medium­ the main building of the Regional Office term programming was introduced and in for the Western Pacific was completed two of them the process was completed. in I978. Ten training programmes in management were conducted-five of them for both I4.I9 The acquisition of a computer national and WHO staff, and five for by the Regional Office for Europe in I 979 nationals alone at the request of individual made it necessary to rent office accommoda­ Member States. A total of 480 people tion, pending the consideration of a pro­ participated. posal for the construction of a permanent extension to the Regional Office building. I4.I4 Training to prepare staff in the regions, both WHO and national, for Spanish-language dommentation primary health care and for the United Nations International Drinking-Water Sup­ I4.20 A service for translating, editing ply and Sanitation Decade was developed and publishing, in the Spanish language, in collaboration with the relevant pro­ the publications and documentation of the grammes. Organization, along with arrangements for distribution, was established in Mexico I4. I 5 The Regional Office for the City.1 The centre will handle the Spanish Americas/Pan American Sanitary Bureau publications of both WHO and PAHO, carried out an extensive training pro­ the programme being financed jointly. gramme, emphasis being placed on com­ munication skills, teamwork, and super­ Supp!J services visory management. Advanced manage­ ment seminars were arranged for senior I4.2 I The steady growth of programme staff. activities was reflected in the work of the supply services, both in the centralized I 4· I 6 At headquarters, two courses of procurement at headquarters and in pro­ refresher training were organized for the curement at regional level. During the administrative assistants and secretaries of biennium I978-I979, the value of supplies four divisions. On the basis of the ex­ and equipment purchased by the Organ­ perience gained, a new programme was ization reached an all-time record of designed which takes the form of a series US $7 4 07 2 8 59 for the two years, repre­ of talks, workshops, and demonstration of senting I I 5 302 line items. To this must be administrative procedures. It is open to 1 all staff, both professional and general See Chapter I 3, paragraph I 3 ·43.

203 THE WORK OF WHO, 1978-1979 added an approximate US $8 900 ooo for Community in particular was active in freight and insurance. assisting several African countries with their health programmes, through WHO's 14.22 The main trends that charac­ procurement services (US $849 700 ). These terized the biennium were: (a) a marked services were also called upon in connexion increase in local purchases by regional with emergency assistance to the malaria offices in the context of technical cooper­ eradication programme in Turkey ation among developing countries (of the (US $2 07 2 270) ; assistance to the most figures quoted above, 7345 line items, in the seriously affected countries through the amount of US$8 696 733, were purchased United Nations Emergency Operation locally) ; (b) inflation running into two (US$1 653 466); and supplies and equip­ digits in many industrialized countries, ment to the Lao People's Democratic and a falling exchange rate for the dollar, Republic and Viet Nam, financed from resulting in higher commodity prices and various extrabudgetary sources and from shipping costs ; and (c) an increase in the WHO's regular budget. Purchases were supplies and equipment component of made on behalf of UNHCR for the long­ projects. term programme of humanitarian aid to 14.23 As part of the WHO emergency Cyprus (US$1 232 678) and for several relief operations, extensive purchases were, small projects to alleviate the situation of as in the past, largely financed from extra­ refugees in Bangladesh, Gabon, Mozam­ budgetary funds. The European Economic bique, Sudan and Zaire (US$543 372).

204 Chapter If

Regional Trendsi

African Region powerful groups prefer confrontation rather than the negotiations that make for greater I 5·I THE AFRICAN Region has social justice. Distressing political events resolutely set out to achieve in Africa are having disastrous effects on health for all by the year zooo, the promotion of health for the under­ notwithstanding-and perhaps largely privileged masses. There have been a because of-the many constraints on such number of attempts to upset the political action. It is the WHO region that has the balance in various countries. Fratricidal greatest number of Member States, of warfare between neighbouring States is newly independent countries, of national incompatible with regional cooperation liberation movements recognized by the through agreements made in a spirit of international community, and of countries solidarity. In southern Africa the escalation figuring on the United Nations lists of least of violence in the name of the racist ideology developed countries and those most of apartheid has led to the few and dearly seriously affected by the economic crisis­ acquired health facilities, hardly sufficient with all that that implies in terms of limited to meet essential needs, being destroyed resources, inadequate infrastructures, pro­ in a matter of days. Moreover, slow fessional staff to be trained, and distress economic growth is coupled with increasing to be relieved. social inequalities that leave two-thirds of I 5.z The report presented in I 979 to the population untouched by the develop­ the twenty-ninth session of the Regional ment process. In the social field selfishness Committee not only provides food for and resistance to change severely hamper serious thought about the future of health the implementation of development stra­ in Africa at a time of world crisis, but also tegies intended to meet the essential needs arouses feelings of alarm and despondency. of the greatest number. Africa-and The world political, social and economic consequently health development in Africa situation is far from conducive to progress -has reached a deadlock, and the years in health in the Region. Faith in an inter­ I978-I979 presage an increasingly doubtful national community characterized by coop­ future unless radical action is taken to eration and mutual dependence is crum­ turn Africa's political, economic and social bling fast. To maintain their privileges, development in a new direction.

1 I Figure 1 5. r on page zo6 shows the location of 5·3 To translate this increased aware­ WHO's regional offices and the areas they serve. ness of African realities into specific devel-

REGIONAL TRENDS opment activities by mobilizing the entire have become "cooperation", i.e., genuine potential of society is the very foundation dialogue and concerted action. For example, of the social revolution in public health. if nutritional assistance is to turn into The conclusions of the Technical Dis­ cooperation, a policy for nutritional self­ cussions at the twenty-eighth session of the sufficiency must be developed. Technical Regional Committee in I978, on the cooperation among developing countries subject of" Social policy and health develop­ in the field of health, properly conceived, ment in Africa", were the outcome of I 5 can become an important element in the years of struggle and study. They clearly establishment of the New International demonstrate that a realistic health policy Economic Order. requires a revolutionary approach. Radical changes in outlook and in mechanisms I 5. 5 In I 978 the Regional Committee set up a Standing Committee on Technical for providing health and social services Cooperation among Developing Countries are inseparable from the political struggle and three subregional working groups, the for health, the essential aim of which is latter meeting for the first time in I979· development and peace through justice. One of the main concerns of Member In order to become what the Director­ States, and of these working groups and General has called "health politicians [who the Standing Committee, was to study will] ensure that the voice of health is specific forms of unconditional support heard in what has been all too often a for the national liberation movements wilderness of apathy", the health leaders recognized by OAU as a way of promoting from the various countries reaffirmed in health development throughout Africa.' Kigali in September I978 the need to The countries of the Region have always strengthen the role of the Regional Com­ cooperated with each other in political, mittee. Member States were urged to economic, cultural and health matters, establish multisectoral coordinating mech­ within the framework of regional or sub­ anisms such as national health councils regional organizations or under bilateral or committees ; to ensure continuity in the agreements. Their cooperation in health work of policy organs ; to apply the deci­ matters chiefly concerns communicable sions intended to promote health at every disease control, training of health personnel, social level; and to facilitate each country's and exchange of teachers, students and participation in carrying out WHO's pro­ health workers. Collective purchasing and grammes-all measures that are pre­ packaging or manufacture of essential requisities for African autonomy in social drugs, medical supplies and equipment, and health matters. and the exchange of appropriate tech­ nologies, are some of the issues currently Technical cooperation among developing countries being studied within the framework of technical cooperation among developing I 5·4 Technical cooperation in the African Region stems from the search for countries. self-reliance as a basis for self-development, and WHO's new programme policies Managerial processes for health development emphasize the importance of health among 15.6 During I978 and I979 considerable the different forms of international coop­ efforts were made to organize educational eration. These are no longer "aid" or meetings and to take an active part in "technical assistance" but-rethought 1 according to the principles of solidarity- Resolutions AFR/RC29/R8 and AFR/RC29/RJ4.

207 THE WORK OF WHO, 1978-1979

practical exercises to improve the under­ political commitment to the concept of standing of managerial processes for health health for all by the year 2ooo. Primary development and their application. Country health care is the approach adopted and the health programming, national programme basis of the regional development strategy. budgeting, national health programme It forms part of the health delivery system evaluation, and national health information but reaches beyond the confines of health systems were closely linked with a view to involve all sectors that directly or to integrating them-no easy task-with indirectly contribute to health develop­ WHO's own managerial processes. These ment. Thus the expanded programme on complex exercises led by stages to a better immunization, the war on hunger, the understanding of the conceptual approach International Drinking-Water Supply and to health development. Sanitation Decade, the campaign against I 5. 7 In I 979 the Institute of Public apartheid, and the International Decade Health, Cotonou (Benin) became a regional for Women are all steps towards the attain­ centre for health development, the first com­ ment of health for all by way of primary ponent of a network of such centres, most of health care. In addition to the first regional which will be national but a few of which centre for health development (preceding will be regional or subregional. The Cotonou paragraph), an African Advisory Com­ centre began its work by providing training mittee on Health Development has been for a multidisciplinary group of develop­ set up, and the regional Advisory Com­ ment workers from French-speaking mittee on Medical Research meets regularly. countries of the African, Eastern Mediter­ ranean and Western Pacific Regions. The I 5·9 From I 977 onwards, but particu­ trainees learn to work as a team and the larly in I978 and I979, the promotion of course is divided into four main parts : primary health care was the core of the (I) general information on health, socio­ development strategy. Nearly all the economic development, communication African countries took an active part in sciences, and audiovisual methods ; (2) both the preparations for and the pro­ management, especially the management ceedings of the International Conference processes referred to above but also staff on Primary Health Care. The Member management, including continuing educa­ States of the Region endorsed the 22 recom­ tion; (3) the eight components of primary mendations of the Conference and sup­ health care considered within the frame­ ported the Declaration of Alma-Ata. The work of national health delivery systems ; main concern now is to mobilize all available and (4) research applied to the solution resources for the implementation of the of health development problems. This new strategies and plans of action. form of training for public health was approved by the Regional Committee.1 15 . I o The concept of primary health Teaching materials consist mainly of WHO care has been clarified and popularized publications and material from the many through the AFRO Ne1vsletter (whose workshops organized in the past. distribution increased from 10oo to 4500 copies in each working language) and Primary health care through workshops and seminars. Instruc­ tion in country health programming I 5.8 Through their leaders, most coun­ includes a section on primary health care. tries of the Region have expressed their With the help of USAID, courses were 1 Resolution AFR/RC29/RI7. organized at the WHO training centres in

208 REGIONAL TRENDS

Lagos and Lome to train instructors in I 5. I 3 Maternal and child health, as part primary health care ; workshops were of activities to enhance the quality of family organized in Ibadan (Nigeria) and Zinder life, received fresh impetus from the pre­ (Niger) in I979 to develop their knowledge parations for the International Year of the of nutrition. A UNDP-financed project Child. Maternal health includes family was prepared, with technical cooperation planning from the point of view of com­ from the German Democratic Republic, munity and individual wellbeing. The for an international course on public health "risk approach" is helping to define target in the United Republic of Tanzania, to groups and establish integrated maternal begin in I98o, in which emphasis will be and child health care units better adapted laid on primary health care. to local needs.

Family health Promotion of environmental health I 5. I I Health education is one of the I 5. I4 Basic sanitation remains essential components of primary health care, which for the promotion of primary health care. presupposes a change in behaviour and new In preparation for the International Drink­ attitudes towards community health. The ing-Water Supply and Sanitation Decade, programme was redesigned during the the Regional Office cooperated with most biennium with the help of a multi­ Member States of the Region in under­ disciplinary group of regional experts that taking a rapid assessment that would enable included mass-media specialists. Health them to draw up programmes and mobilize education is a slow process, and efforts are the necessary resources. Many countries being made to speed it up by mobilizing have established structures for formulating all available resources-the mass media, policies and preparing development plans. institutions for the development of human Training in resource management is pro­ resources, and programmes for health vided for the staff concerned. There are promotion and protection. Courses on sanitation units in the public health minis­ health education are given in Ibadan, tries of 24 countries, and seven other coun­ Nigeria, at diploma level (40 students) and tries have set up ministries of the environ­ for a master's degree (I 5 students); in Lome ment. (3 5 students) ; and at the regional centre for health development in Cotonou, Benin. Disease prevention and control I 5• I 2 Within the framework of primary health care, special emphasis is given to I 5. I 5 Most of the Region's resources are food and nutritional surveillance. Health still spent on the surveillance and control promotion requires the support of all the of the main communicable diseases. In I978 related sectors of community development, and I 979 localized cholera epidemics broke such as crop-growing, animal husbandry, out in six countries and yellow fever in one and food production. Since I978 a regional country-incidents that show how much network of national centres has been in epidemiological surveillance still requires existence which emphasizes research and strengthening. The implementation of the training (Congo, Ethiopia, Nigeria, new malaria control strategy offers an Rwanda, Senegal, United Republic of excellent opportunity for promoting tech­ Tanzania, Upper Volta, and Zambia). The nical cooperation among neighbouring revision was prepared of a manual on public countries with similar epidemiological situ­ health nutrition that is out of print. ations ; it is essential that they adopt

209 THE WORK OF WHO, 1978-1979 common objectives and coordinate their Prophylactic, diagnostic and therapeutic malaria control activities at the various substances stages of planning and implementation. Now that smallpox has been totally eradi­ I 5• I 9 The action programme on cated from the Region, further develop­ essential drugs implies the development ment of the expanded programme on of drug policies and management systems immunization will be possible. that correspond to people's needs. In order to make essential drugs available to I 5• I 6 The onchocerciasis control pro­ the entire population at a cost that the gramme in the Volta River Basin area is pro­ various countries can afford, WHO joined gressing satisfactorily. Studies with a view to with those countries in studying how to extension were undertaken in western Mali organize collective bulk purchasing, and the Senegal river basin. In cooperation planned well in advance, which would with WHO, Nigeria is preparing to carry considerably reduce costs and would not out its own programme in which priority necessarily be to the manufacturers' dis­ will be given to protecting the district advantage. This is a specific case where around the new federal capital. Strategy the mechanisms of technical cooperation and tactics similar to those used in the Volta among developing countries can demon­ River Basin area will be applied in these strate their efficacy and where concerted various campaigns. At the same time action is vital, particularly since distribution efforts are being made to find methods of circuits need reorganizing so that the entire control that are less complex, reasonable community can benefit from them. in cost, and equally effective. (See also Chapter 9, paragraphs 9·54-9.6I). Health manpower development

I 5. I 7 The control of noncommunicable I 5.20 The integrated development of diseases such as cardiovascular disorders and health services and training of personnel cancer requires new approaches that take calls for renewed effort to combat resistance greater account of the promotion of primary to change. To continue imposing on health care and of the epidemiological fact African countries educational systems that that many forms of these diseases are the have not proved their worth even in the result of untreated or inadequately treated highly industrialized countries is merely communicable diseases or nutritional de­ obsolete paternalism and contrary to the ficiencies. spirit of solidarity. The research and the attempts at innovation of several countries Mental health of the Region in training their health pro­ fessionals are highly encouraging. I 5. I 8 The special programme on mental health in southern Africa is another example Research promotion and development not only of technical cooperation among developing countries but also of combined I 5. 2 I Another promising area of efforts by national and WHO staff to imple­ activity is the organizing and strengthening ment joint mechanisms such as national of biomedical and health services research, coordinating groups, the regional action or, more simply, health research; and here group, the exchange of teachers and con­ in particular the African Region must sultants, and the coordination of training redouble its effort. What is needed is not programmes. so much the simple transfer of technology

2IO REGIONAL TRENDS as the acquisition of an organized body of Region of the Americas knowledge and techniques adapted to local needs. In this area too, cooperation I 5.24 The extension of health services among countries with similar problems coverage by way of primary health care is will be decisive evidence of regional and the outstanding trend in the Region, and international solidarity. the spearhead in the regional effort to attain health for all by the year 2000. * * * I5.25 In order to determine their future I 5.22 The main features of health work action, the governments of the Americas in the African Region in I978-I979 were decided to evaluate their efforts, strategies the consolidation of previous achievements and policies in the health field over the and the institution of structures to ensure past ten years. In defining their priorities more rationalized planning, programming, and strategies, they are taking into con­ management and evaluation of health sideration the serious demographic situa­ delivery systems. Among the measures tion, the urbanization phenomenon, the required are the establishment of multidis­ availability of foodstuffs and nutrients and ciplinary and intersectoral structures, the their accessibility to the population, and the reorganization of training for public health, complex relationships between the factors and the reorientation of research towards affecting the human environment. They community problems ; these are also com­ are also studying the availability of resources ponents of primary health care, which is and problems of health system organization recognized throughout the Region as the and operation. main strategy for health development. Such a holistic approach is essential for the I 5.26 All are in agreement that the countries of the African Region, since no attainment of health for all by the year health budget can keep pace with inflation 2ooo demands new social and economic and the ever-rising costs of essential approaches, and that primary health care is products. the key strategy. They recognize that the primary health care concept goes far beyond I 5. 2; Technical cooperation among a simple extension of health services developing countries may prove an impor­ coverage and implies a need for intersectoral tant tool for health development. The policies whereby the health sector benefits Region's health strategy from now until from the other sectors of socioeconomic the year 2000 will be directed towards development, and that the achievement of a gaining a thorough understanding of socio­ higher level of health requires the participa­ economic development and of its links with tion not only of those sectors but also of health policy. The driving force and prime the community itself. mover in this strategy is the national ministry of health, through its activities in I 5. 2 7 In several countries that are at the mobilizing political forces and the strength first stage of formulating national strategies of the community so as to bring about a and reorienting national health processes genuine revolution in health. It can reach the trend is towards strengthening the its full operational effectiveness only when relationship of the health sector with other the entire potential of the community has sectors, seeking new approaches and new been harnessed to action that the community technologies, integrating into one system itself esteems essential. the various components . of the health

2Il THE WORK OF WHO, 1978-1979 sector, coordinating the development of economic awareness on the part of the human resources to meet the new require­ population. ments of that system, and defining national policies for its financing. There is also a I 5• 3 I Countries are increasingly con­ marked trend towards strengthening links scious of the need for a change in develop­ between countries and towards coop­ ment style and as a result are trying out eration at the subregional level, in the spirit innovative approaches to produce the of technical cooperation among developing necessary impact instead of relying on countries. linear growth or the sporadic application of resources to isolated pr,ojects. I 5.28 Refinements of the internal struc­ tures of the Pan American Sanitary Bureau I 5• 3 2 There is increasing evidence of were implemented to improve the effec­ sociopolitical awareness in health action, tiveness of the Region's capacity for witness the definition of an all-inclusive meeting the goal of health for all by the "profile of wellbeing", in which health year 2000. is the central component ; the adoption of strategies explicitly intended to fight extreme poverty, recognized as the principal I 5.29 The technical divisions at the obstacle to meeting basic social needs ; central office were realigned and will be the new intersectoral articulation and responsible for regional programming and integrated development programmes ; and evaluation, for preparation of technical the adoption of inter-institutional patterns norms and criteria, and for implemen­ of collaboration. In short, health is seen tation of regional programmes. The Pan less as an isolated activity and more as a American centres for research and training component of comprehensive socio­ will undergo extensive review and evalu­ economic development. ation to improve the Organization's capacity for technical cooperation. An I 5• 3 3 An increase in national resources Operations Manager was appointed in is accompanied by an increase in financial to coordinate the supervision and I979 and technical cooperation on the part of monitor the implementation of activities the international agencies. A take-off in at the country level. health coverage extension programmes is perceptible, in which physical and tech­ nological development takes place in a Comprehensive health services context of integrated development.

I 5. 30 It is estimated that the total I 5. 34 The principal innovations cor­ population of twenty of the developing respond to the operational concepts of countries of the Region will reach Goo primary health care-community organiza­ million by the year zooo, with 7 5 % of tion and participation ; articulation of that population concentrated in urban areas. formal and traditional health systems ; This represents a doubling of the popula­ promotion of appropriate technology ; and tion in 30 years. A proportionate increase technical cooperation among developing in the demand for health services coverage countries in technological development. can be expected. Moreover the quantitative These concepts are being promoted and growth in basic needs will be compounded their realization emphasized by policy by the expectations created by socio- measures and high-level planning. Their

2I2 REGIONAL TRENDS application represents a breakthrough in examples of such integration. In several extension of coverage. Health services countries of Latin America and the will no longer be services extended to a Caribbean, integrated leprosy and tuber­ passive recipient ; and community involve­ culosis programmes have been started. ment in health work-especially in primary I 5. 38 A growing number of activities care-will have a muliplier effect and a are being carried out in the context of corresponding impact on the development technical cooperation among developing of health services. countries. There is a trend toward closer cooperation among experts and institutions I 5. 3 5 Thus, the implementation of plans of several countries of the Region in and programmes will depend on the success relation to noncommunicable diseases. In of three basic strategies : (I) strengthening laboratory services, PAHOfWHO has pro­ of the planning function and its role in moted the idea of control centres for bio­ health development; (z) development of logical products in the various subregions human resources to bridge the quantitative that would provide services for several and qualitative gap in health manpower ; adjacent countries. Under the expanded and (3) institutional development of the programme of immunization a research health services as a means of improving project to determine needs in measles operational capacity, optimizing the utiliza­ vaccine in five countries has proved a tion of resources, and increasing respon­ mechanism for information-sharing on siveness to change. coldchain developments. Leprosy activi­ ties were based in Venezuela, where a regional centre cooperates with Latin Disease prevention and control American countries; a Caribbean Steering Committee has been established for guiding I 5. 36 Technical cooperation act1v1t1es activities in the English-speaking in disease prevention and control are being Caribbean. A centre in Argentina, under progressively integrated into comprehensive the auspices of UNDP and PAHO/WHO, policies for extending health services is concerned with a haemorrhagic fever coverage, using the strategy of primary vaccine that can be used in both Argentina health care. Such activities as the expanded and Bolivia and possibly in other parts of programme of immunization, diarrhoeal the world. An extensive laboratory net­ disease control based on oral rehydration, work has been developed in the Caribbean BCG vaccination under the tuberculosis for the rapid detection and diagnosis of programme, measures for the prevention yellow fever and dengue. of blindness, and extension of malaria control can be effective only if they are carried out wih the full participation of the I 5. 39 The Organization is also community and of front-line health care emphasizing the use of extrabudgetary personnel. resources to promote new fields of activity and to expand old ones. Extrabudgetary I 5. 37 The integration of specialized resources have made possible an extension disease control activities into the general of the leprosy programme, the expansion health services has been gradually promoted of the diarrhoeal disease control pro­ -the expanded programme of immuniza­ gramme, and a programme of disaster tion and the programmes for tuberculosis relief including preparedness for emer­ control or prevention of blindness are gencies.

2I3 THE WORK OF WHO, 1978-1979

Promotion of environmental health health workers, and the public to reasonable and achievable levels. I5.4o A priority of PAHOfWHO for the next decade is the extension of water Human resources and research supply and sanitation services, particularly in urban fringe and rural areas. Countries I 5·4 5 During the biennium the main will be helped to prepare national plans emphasis was on introducing and expand­ for extending such services during the ing the medium-term programme approved International Drinking-Water and Sanita­ by the Regional Committee in I977· A new tion Decade ; to provide technical guidance strategy is now being shaped that is based on the operation and maintenance of water on the establishment of comprehensive systems ; and to prepare project proposals manpower development programmes at for submission to national, regional, inter­ subregional and country levels, in a con­ national and bilateral funding and lending certed action to cover all dimensions of institutions. manpower needs in the health field. It includes planning, training, and use of personnel and is closely coordinated with I 5.4I Existing institutions in selected plans for extending health services coverage countries of the Region will be strengthened. to underserved populations. A network of specialized collaborating institutions is expected to work closely I 5.46 Priorities in education will be with PAHOfWHO research and training oriented to the training of intermediate and centres-the Pan American Center for auxiliary level personnel. In research, Human Ecology and Health, and the Pan emphasis will be given to communicable American Center for Sanitary Engineering disease control, nutrition, maternal and and Environmental Sciences-in carrying child health, and health services research. out investigations and training programmes. I5·47 Among PAHOfWHO's com­ prehensive manpower development pro­ I 5.42 Countries will be encouraged to formulate solid waste management pro­ grammes, those for the education and grammes and to set up national planning training of allied health personnel in the and technical support agencies. Caribbean, strategic training of health personnel in Brazil, and training in commu­ nity health for Central America and Panama I 5·43 The expected increase in air, are examples of the new strategy. A similar water and soil pollution will require an approach is contemplated for countries acceleration of the collaborative programme of the Andean subregion. In all these pro­ with Member governments to evolve grammes, the Organization's strategy realistic environmental health criteria and emphasizes action adapted to the socio­ standards and to assess the adverse effects economic context of the area or subregion. on human health of industrialization and It is based on establishing a central focus urbanization. at field level to maintain continuous linkages with a network of peripheral activities so I5·44 Work on the hazards of radiation as to ensure that the development and will be directed to ensuring the optimum expansion of the training programmes are utilization of radiation medicine and constantly related to the needs and priorities limiting the radiation exposure of patients, of the country in question.

2I4 REGIONAL TRENDS

Technical cooperation among developing countries I5·5I The year I978 marked a change in the discussions on the regional pro­ I 5.48 Technical cooperation among gramme budget, which centred primarily developing countries (TCDC) has become on a detailed analysis of the needs of an increasingly important policy instrument Member States and of what their govern­ and the regional programmes embody its ments expected from the Regional Office. principles, which are inherent in the This new approach will make for a pro­ structure of the Organization and also gramme budget with better coordination in the Pan American centres and institutes, of resources at country, area and regional whose technical resources and skills come level, and with sufficient flexibility to allow mostly from the developing countries of for adaptation to the individual require­ the Region. Within the framework of ments of each country or subregion. TCDC, PAHOjWHO acts as a catalyst in the extension of health services coverage and has promoted the transfer of approaches Special programme of animal health that have emerged from national I 5. 52 To the more than 3oo million experience. people living in Latin America and the Caribbean, the zoonoses and other animal I 5·49 The establishment of coordinating units in Member countries is necessary if health problems are matters of vital information is to be obtained and exchanged importance. More than half the population on the national technical capacity, the tech­ is rural and lives in close contact with nology being used, the teaching resources domestic animals-frequently they are in available, and the capabilities existing for close proximity to wild animals as well. production of supplies, equipment, etc. Countries depend heavily on livestock­ Once such information exists, criteria can raising both to feed themselves and, be established to govern regional mech­ increasingly, to earn foreign exchange anisms for TCDC information, its exchange by the export of meat and other animal between countries, and the role of the products. Regional Office in facilitating, strength­ I 5. 53 Through its special programme ening and disseminating such information. on animal health PAHOjWHO will con­ tinue to cooperate with Member States Managerial processes for health development of the Region in developing and strength­ ening programmes for foot-and-mouth I 5. 5o The Regional Office will continue disease and zoonosis control. The Pan to strengthen and streamline the mech­ American Zoonoses Center (Argentina) anisms of its programming and evaluation and the Pan American Foot-and-Mouth system, so as to permit the better struc­ Disease Center (Brazil) constitute a special­ turing and organizing of the various phases ized resource and give support to the con­ in the formulation, execution, and evalua­ cept of technical cooperation among tion of technical cooperation programmes. developing countries. It will, through its advanced word­ processing and computer programmes, Extrabudgetary resources for health work provide up-to-date information on the 43 regional programmes, 33 country I 5. 54 There have been sizeable increases profiles, and some 38o national programmes in the extrabudgetary funds from nearly in which PAHOjWHO collaborates. all sources over the last four years. Nearly

2I5 THE WORK OF WHO, 1978-1979

43% of the total PAHOJWHO funds formulating national strategies, plans of budgeted for I979 came from extra­ action, and programmes to achieve the budgetary sources. Grants from founda­ social goal of health for all by the year zooo. tions and similar bodies showed the biggest All Member States in the Region are fully increase, almost doubling over the four­ committed to the principles of primary year period and amounting to I9·4% of health care and accept them as the basic the total extrabudgetary funds in I979· approach for reaching that target. This theme has permeated all WHO activities I 5. 5 5 The indications are that the trend and meetings in the Region, including the towards further increases in real terms of thirty-first and thirty-second sessions of extrabudgetary funds from regional banks, the Regional Committee. foundations and bilateral sources will continue. Careful selection and monitoring I 5. 59 An important milestone was the of projects financed by such funds will be unanimous adoption by the Regional Com­ required in the interests of maintaining the mittee in I978 of the Charter for Health standards of performance habitually Development, which will be implemented expected from PAHO/WHO projects. as soon it has been formally signed by Member States. It will provide a regional I 5. 56 The three main areas benefiting mechanism for mobilizing both internal from extrabudgetary funding are : primary and external resources for health develop­ health care and extension of health services ment and a focus for intercountry consulta­ coverage ; development of human tion and collaboration in the spirit of tech­ resources ; and water supply and environ­ nical cooperation among developing mental health projects. countries. I 5. 57 A significant development at the Regional Office was the reconstitution in Health services development I979 of the Project Review Group, which I 5.6o During the last few years, the is under the chairmanship of the Deputy countries of the Region made considerable Director and includes the heads of the progress in evolving health plans more technical divisions and the legal adviser. suited to the needs of their people. Country All projects financed from extrabudgetary health programming has greatly contributed funds are now subject to a formal review to this progress in most countries. In all by this group, which recommends to the of them, the planning process is being Regional Director what course of action increasingly integrated with planning for he should consider. This review process overall socioeconomic development. should ensure that in the future projects funded from extrabudgetary funds are I 5.6I The upsurge of interest and fully consonant with the overall plans for concern evident at the Alma-Ata Conference health development of the country in was followed up throughout the Region. which they are carried out. Out of its ten countries, Bangladesh, Burma, India and Thailand have already formulated and started implementing national pro­ South-East Asia Region grammes of primary health care. Other countries are either at the planning stage I5.58 During I978-I979 a series of or are experimenting with alternative activities in the countries of the South­ models that fit their political, cultural and East Asia Region were directed towards socioeconomic situation.

2I6 REGIONAL TRENDS

I 5.62 National preparatory activities in I 5.66 In regard to manpower develop­ the form of seminars, working groups, etc., ment in family health, technical support took place in India, Indonesia and Thailand was given to the reorientation of both basic in preparation for a meeting at the Regional and continuing education programmes to Office (December I979) on the formulation meet the changing health needs of Member of strategies for attaining health for all by countries, the elaboration of training pro­ the year 2000. In this meeting, sponsored grammes in keeping with the spirit of jointly by UNICEF and WHO, national TCDC, and the promotion of national self­ representatives from sectors other than reliance in the training of various categories health, e.g., planning, plan implementation, of maternal and child health personnel. and rural development, took part. I 5.67 Technical support was also given to planning studies on the "risk approach" I 5. 6 3 Governments are conscious of the contribution health can make to the New in the delivery of maternal and child health International Economic Order and are care in certain countries that had already taking action at national level to ensure completed their studies on the outcome of that the strategies they develop in the health pregnancy (including perinatal mortality field are adequately reflected in the new and morbidity and low birth weight). international development strategy ; that WHO cooperated in improving neonatal sufficient additional resources are allocated care through national training programmes, to the health sector; and that they are pre­ and in building up maternal and child ferentially utilized for improving the health health information systems at national level. of the socially underprivileged. I 5.68 In an attempt to develop a comprehensive nutrition programme, dis­ I 5.64 The increasing emphasis on tech­ cussions were held with policy-makers, nical cooperation among developing planners, health administrators, and nutri­ countries (TCDQ and on the use of appro­ tion scientists in seven countries ; they priate technology for health was apparent were followed by an intercountry workshop when the Regional Committee, at its to formulate a comprehensive research­ thirty-second session, discussed these vital cum-action programme for the Region. topics for the fourth consecutive time. It The highest priority was given to projects expressed its appreciation of the TCDC conducive to an effective and feasible pro­ directory of training and research institu­ gramme of nutrition within the primary tions produced by the Regional Office. health care system. Detailed methods, pro­ tocols, and experimental designs for such I 5.65 The main thrust in the family projects were developed for adaptation by health programme during the period was researchers to specific country situations. the extension of coverage to underserved populations, with emphasis on the groups I 5.69 In those places of the Region at greatest risk, and the development of a where nutrition improved during the programme based on the new and wider biennium, it was due to social development concept of family health. In particular, (including general education), improved family planning, in keeping with the income distribution, or general health national policies of several countries, was measures rather than to traditional direct oriented within the broader scope of family action. Intersectoral collaboration and the welfare. coordination of planning at every level is

2I7 THE WORK OF WHO, 1978--1979 therefore essential if any impact is to be view to making better use in primary made on malnutrition. This in turn high­ health care of practitioners of traditional lights the need for interagency coordina­ medicine. tion in support of national activities, and also the role of national nutrition units in I 5. 7 3 A new trend is the attention being developmental planning. given to mental health and to the mental health component of country health pro­ gramming, national health information I 5. 70 The countries of the Region are g1v1ng prominence to the health education systems, primary health care, and traditional component of primary health care, so that medicine. A regional advisory group on people become responsible for prevention mental health was set up with rep­ of disease and promotion of health through resentatives from public health administra­ their own voluntary efforts. They are also tion, social and behavioural sciences, and using health education to involve the psychiatry. Areas of concern include child community in the planning, implementation mental health, dependence on alcohol and and evaluation of primary health care other drugs, and the role of psychosocial services and to enlist its support in main­ factors in health. taining these services. Governments there­ fore need training programmes of which Disease prevention and control an essential part is training in health educa­ tion, and these require new curricula, I 5·74 In the prevention and control of communicable diseases efforts concentrated methods, material, and field practice. mostly on malaria, mycobacterial diseases (leprosy and tuberculosis), diarrhoeal I 5. 7 I The concomitant strengthening diseases, and the expanded programme on of other closely related programmes in immunization. Epidemiological surveil­ support of primary health care continues, lance systems in countries of the Region e.g., development of a sound referral gradually improved, the stress in WHO's system, logistic support, maintenance and programmes being on developing epide­ repair of equipment, and community-based rehabilitation. Stress is laid on the proper miological capabilities through field train­ ing in actual work situations. development of health laboratory services, both for facilitating the diagnostic process I 5·75 Malaria activities continued to be and as an aid to epidemiological surveil­ given priority. During the period under lance. WHO also continues its support to review, 885.6 million people were covered the strengthening of reference laboratories. by antimalaria programmes out of a total In all these activities there has been close of 942.4 million at risk. The trend of the collaboration with UNICEF and other disease in terms of parasite incidence is organizations of the United Nations system. encouraging, slide positivity rates showing a decrease of 22% in I978 as compared I 2 5. 7 Programmes in traditional medicine with the decrease of a little over I 5 % in have received increasing attention. A I977· The decreasing trend of Plasmodium research study group on the subject (March falciparum infection also continued, although I978) was followed by a regional consul­ to a reduced extent. tative meeting (April I979). Constraints on the use of traditional medicine have been I 5. 76 Progress was made in training identified and recommendations made for and in applied field research. A regional improving training programmes with a malaria training programme was instituted

2I8 REGIONAL TRENDS with a view to strengthening national research programme on epidemiological, training and providing staff to implement therapeutic and preventive aspects is being the revised malaria control strategy. developed. The rifampicin trial in Burma Collaborative studies on resistance of made satisfactory progress. P. jalciparum to 4-aminoquinolines are progressing satisfactorily in seven countries I 5. 8 I Diarrhoeal diseases, especially in of the Region. children, were also recognized as a priority. A comprehensive research-cum-action pro­ I 5. 77 To overcome the shortage of gramme was drawn up with emphasis on insecticides, a gradual effort was made to rehydration, and its implementation was increase production of DDT in Bangla­ begun. desh and in India, where the output is likely to be doubled with the commissioning I 5. 8 2 Among the viral diseases, dengue of a third factory. haemorrhagic fever, although generally restric­ ted to Burma, Indonesia and Thailand, I 5. 78 National coordinating com­ showed a tendency to spread to other mittees were set up in a number of countries countries as evidenced by a severe outbreak and intercountry border meetings con­ in Maldives and sporadic cases in Sri Lanka. tinued. WHO's work was directed towards strength­ ening surveillance and developing multi­ I 5. 79 As regards tuberculosis, routine centre and multidisciplinary research on BCG vaccination and systematic case detec­ clinical and epidemiological management. tion and treatment continued. Valuable progress was recorded by the Tuberculosis I 5.8 3 In the field of veterinary public Research Centre, Madras (India), in devel­ health, rabies and brucellosis continued to oping a nontoxic, inexpensive, and readily be of priority concern, the main thrust acceptable chemotherapeutic regimen for being directed towards manpower develop­ mass domiciliary treatment in devel­ ment and research on prophylactic vaccines. oping countries. A large-scale trial to assess the value of BCG vaccination in preventing I 5. 84 In the expanded programme on tuberculosis was completed in India, with immunization attention was directed towards the joint support of the Indian Council of manpower development and suitable Medical Research and WHO. A preliminary logistic systems, including a dependable analysis of the results indicates the need for cold chain. Immunization coverage greater attention to the epidemiological increased gradually in all countries, and the significance of the entire range of myco­ functioning of existing cold chains bacteria in general and of low-virulence improved rapidly. The in-built evaluation Mycobacterium tuberculosis in particular (see systems introduced by some countries led also Chapter 9, paragraph 9· 78). to improvement of the programme.

I 5.So In lepro!J, while the traditional I 5. 8 5 With regard to vector biology and measures for identification, treatment and control, a new trend towards comprehensive case-holding continued, there was a notice­ and integrated programmes for the control able trend towards integrating antileprosy of the major vectorborne diseases is gaining measures into the general health services. ground. Such a programme has been Since leprosy was declared a priority area developed in Burma for the control of for research by the regional advisory com­ malaria, filariasis, dengue haemorrhagic mittee on medical research, an intensive fever and Japanese encephalitis; it is THE WORK OF WHO, 1978--1979 supported by CIDA, the Government of formulate projects visited Bangladesh, the Netherlands, and WHO. Burma, India, Indonesia, Nepal, and Thai­ land. Programmes are now being reoriented 15.86 In the field of noncommunicable and priority projects formulated in detail. diseases priority attention continued to be A regional consultation on policy planning, given to the prevention and control of coordination, and implementation of the cancer, cardiovascular diseases, and blind­ health and engineering programme (N ovem­ ness or visual impairment. Other emerging ber I979) set regional targets and specified public health problems included rheumatic appropriate strategies. conditions, chronic liver diseases (including liver cancer), deafness, chronic obstructive I 5.89 At the same time the countries pulmonary disorders, and diseases related to of the Region, realizing that the environ­ immunological disturbances. Epidemio­ mental problems arising from industrializa­ logical studies, research and training were tion cannot be left for solution at a later promoted in the early detection, diagnosis date, are increasingly requesting WHO's and management of diabetes, which is pre­ cooperation in developing criteria, methods, valent among the rural poor in Bangla­ and procedures to minimize the adverse desh and other countries of the Region. impact of such development on health, Group educational activities were under­ and seeking its advice on various aspects taken to stimulate community-oriented of water and air pollution. A regional measures for prevention, control and seminar was held to review methods of rehabilitation as related to cor pulmonale. assessing such impact. Under the UNDP/ UNESCOfWHOfWMO water quality Promotion of environmental health monitoring project-a part of the Global Environmental Monitoring Systems I 5.87 For at least a decade the provision (GEMS) in operation in this Region-a of safe drinking-water and the sanitary training course was organized for personnel disposal of excreta will remain the main from reporting stations. field of work in environmental health. All governments recognize that the ad hoc I 5.90 Another recent trend is shown project approach by a single agency must by the number of requests received for give way to integrated planning as part technical cooperation with a view to food of overall socioeconomic development ; safety programmes. and that the coordination of external co­ operation is vital if assistance is to be Health manpower det;elopment channelled to the poorer population as yet unserved. This is evidenced by the resolu­ I 5.9I A number of countries in the tions passed at regional intergovernmental Region sought WHO's collaboration in meetings and at the United Nations Water formulating programmes for planning of Conference. health manpower, and the importance of such planning was given recognition in 15.88 Rapid assessments of the situa­ country health programming. Various tion were undertaken with external activities to promote coordination between resources from the WHO/World Bank the health services and manpower develop­ cooperative programme, UNDP, and the ment agencies were undertaken. Federal Republic of Germany. Preliminary appraisal missions to determine the con­ I 5.92 The need for formulating health straints on programme development and manpower development strategies for

220 REGIONAL TRENDS primary health care was very apparent, and on resource-sharing, the concept of a health the training of health teams and of multi­ information network, health literature and purpose health workers is a vital element library services, and publication of manuals, in the emerging primary health care pro­ guides, etc. grammes. Assistance is being given to training programmes for multiprofessional I 5·97 The trend towards regionaliza­ teams and in setting up institutions for tion of the WHO fellowships programme health services research. Health manpower was carried further : in I 979, 43% of the development is a priority area for research, fellowships were awarded for study within which is being undertaken on as wide a the Region as compared with 25% in I976. scale as possible. A consultative meeting was held to discuss ways and means of making fellowships I 5·93 Priority attention was given to more useful to countries in the light of the review and reorientation of training their special needs, and to devise mech­ programmes in maternal and child health, anisms for eliminating various problems sanitary engineering, and epidemiology that arose in relation to the planning, in order to make them more relevant to processing, and implementation of the local needs and resources. Curricula for fellowships programme. various categories of health workers were revised to orient them towards community Research promotion and development health. W ark was also undertaken to enhance the capabilities of nursing per­ I 5.98 The regional research pro­ sonnel for carrying out operational research gramme, initiated in I 976, expanded as to determine the needs of communities from mid-I978 and by September I979 and the ways in which nurses can best some 70 research projects had received assist in meeting them. support. These research studies cover such priority fields as diarrhoeal diseases, dengue I 5·94 The idea of achieving regional haemorrhagic fever, malaria, filariasis, self-sufficiency through technical coopera­ leprosy, liver diseases, traditional medicine, tion among developing countries is gaining human reproduction, and appropriate tech­ momentum. An intercountry consultation nology for improvement of environmental on the development of postgraduate train­ health. Several studies in the field of ing institutions recommended that high nutr1t1on had already been initiated. priority should be given to strengthening National consultative meetings on health specialist services at the intermediate-care services research are also in progress. level. I 5·99 To develop research manpower I 5·9 5 National group educational meet­ and strengthen research institutions, ings for the dissemination of information support was given to training the relevant and the exchange of ideas received greater manpower. In I 978, I 3 research training emphasis, and here programmes in educa­ grants or grants to enable scientists to tional methods and teacher training played visit other institutions were awarded in an important part. the Region, and in I979 (as at the end of September) 20 such grants had been I 5.96 There is a great need for cheap awarded. Approximately 50% of those learning materials in the Region, and steps receiving the grants utilized centres within are being taken to assess the situation with the South-East Asia Region, thus pro­ a view to a programme in this field based moting technical collaboration and exchange

221 THE WORK OF WHO, 1978--1979 of technical experience among countries to the Regional Programme Committee. of the Region. In addition, the Regional That Committee carries out a continuous Office is taking steps to provide courses on review of existing management systems research methods for scientists, both at with a view to making them more efficient basic level and in specific research areas. and effective.

I 5. I oo In response to Health Assembly resolutions calling for coordinated and European Region comprehensive national research pro­ grammes involving medical research coun­ I5.I04 Even in I978-I979 the reorien­ cils, the Regional Office in December I979 tation of WHO's future programme towards convened a meeting of heads of medical the attainment of health for all by the year research councils and responsible officers zooo began to influence the substance of for research in the relevant ministries ; the current programme. That programme the meeting produced guidelines for coor­ continued to serve the needs of the devel­ dinated national programmes and defined oping countries of the Region by drawing areas for collaboration with WHO. on extrabudgetary resources, e.g., for work 5. IOI For the I980-I98 I biennium, on leprosy or diarrhoeal diseases, while at research projects financed from national the same time orienting the intercountry budgets have been formulated for seven activities towards the problems of the countries. They are geared to the immediate industrialized world. research needs of the country and will be complemented by an intercountry project 5. I o 5 This latter process is made inevi­ on research promotion and development. table by the extent of industrialization in the Region but it also has potential value for the developing countries. The results, ProgratJJme planning and direction for instance, of the European cardiovascular I 5. I 02 A number of new act1v1t1es disease programme, begun in I968, are initiated by WHO to improve the planning already being universally applied ; and the and direction of its programme came to recommendations regarding the alcohol and fruition during the period under review drug abuse component of the European and have contributed to a substantial mental health programme, I97o-I98o, improvement in programme delivery should make a significant contribution to through a restructuring and strengthening . the immediate preventive action called for of the management system. by the Thirty-second World Health Assem­ bly with regard to alcohol-related problems I 5. I03 During I979 the Regional Office (resolution WHA32.40 ). Similarly, it is took initial steps in working out regional appropriate that the Regional Office for strategies for attaining health for all by Europe should be coordinating the develop­ the year 2ooo. The work of the Regional ment of global programmes for the pre­ Programme Committee was reviewed, vention of road traffic accidents and for reorganized, and streamlined to enable it health care of the elderly. to concentrate on overall policy and pro­ gramme development. The functions of I 5. I o6 In order to achieve a balanced the programme support and coordination intersectoral approach to health promotion, unit of the Regional Office were also WHO's country health programming guide­ reviewed to make it an effective secretariat lines are being adapted to the needs of the

222 REGIONAL TRENDS

Region. The biennium was a period of of assessment stimulated the publication streamlining the system for collecting, Measurement of Levels of Health, 2 which was screening, storing and disseminating infor­ jointly sponsored by WHO and the Inter­ mation on the health activities carried national Epidemiological Association and out by other intergovernmental organiza­ is intended as a guide in allocating resources, tions in Europe. planning and monitoring health and health­ I 5. I 07 The new regional research pro­ related services, introducing innovations gramme made steady progress, producing and reviewing existing services or pro­ recommendations in five priority areas grammes. Here again, the methods out­ (evaluation of drugs and other therapeutic lined are feasible in most countries, although or diagnostic substances ; early detection the book is slanted towards the European and prophylaxis of disease ; health care Region. delivery ; economic aspects of health care ; 3 and standardization of methods, measure­ Health care of the elder(y ments and terminology). It was moreover I 5. I Io Reorientation of services for the proposed that the Regional Office should elderly received an impetus from the act as a clearing-house for projects in Declaration of Alma-Ata, which called for hypertension research as related to health soundly based and socially accepted services care. Other European bodies concerned to the individual and the family at com­ with health services research are involved munity level. Thus the regional activities at all stages. were broadly directed at establishing the needs of the elderly, comparing the ways by Development of comprehensive health services which these needs are met in different I 5.108 Although the primary health countries, re-examining the technology care approach in Europe is different from used, and promoting awareness of the that envisaged for the developing world, implications that the rise in the number of the Declaration of Alma-Ata incorporates elderly people will have for the family, the several principles that apply equally to both community, and the health services. developed and developing countries. More­ over front-line care has not always pro­ Road traffic accidents 3 gressed smoothly and evenly in all coun­ I 5. I I I The two consultative groups on tries ; over-emphasis on sophisticated hos­ road traffic accidents in I977 were followed pital-based services, for example, has often in I978-I979 by several scientific groups, by been detrimental to such care. The new various studies, and by a strengthening of emphasis on primary health care is there­ contacts with national transport depart­ fore equally welcome in the European ments and research institutes for traffic Region. The publication Primary Health safety. The programme's main objective is 1 Care in Europe describes the main prob­ to review those problems that are of concern lems in the Region and proposes new in public health and promote the appli­ strategies for their solution. cation of the results not only of research on I 5. I09 Evaluation of health pro­ traffic safety but also of medical research. grammes and services is crucial for health It seeks on the one hand to give a clear administrators. The demand for methods 2 Holland, W. W. et al., ed. Measurement of levels of 1 Kaprio, L. A. Primary health care in Europe. Copen­ health. Copenhagen, World Health Organization, 1979 hagen, World Health Organization, 1979 (EURO (WHO Regional Publications, European Series, No. 7). Reports and Studies, No. 14). 3 See also Chapter 5, paragraph 5.28. THE WORK OF WHO, 1978--1979

picture of the medical and social conse­ were followed up in the medium-term quences of road accidents so as to facilitate programme, formulated in I 979· the planning of services for the treatment I 5. I I4 The successful courses in family and rehabilitation of the victims, and on the healthjfamily planning, run jointly with the other hand to define the role of the public International Children's Centre, continued. health authorities as regards preventive Until recently, cooperation in family plan­ measures and indicate the strategies they ning was mainly with developing countries should employ. but is now being extended to other Member States, with the financial assistance of Fami!J health UNFPA. I 5. I I 2 Existing services for the age Mental health group 5-I8 years are inadequate or in­ appropriate to the situation created by rapid I 5. I I 5 The consultative committee on socioeconomic development and industri­ the European mental health programme alization in the Region. Important changes recommended that even greater emphasis are taking place in the role of women and in be placed on the mental health aspect of behavioural patterns of human repro­ community health programmes. This duction, as evidenced by falling birth rates, requires a better definition of roles and the increasing employment of women, and functions within health service systems the growing number of adolescent preg­ and of the various mental health professions. nancies. Perinatal and infant mortality rates The project to study mental health services are falling appreciably, and greater emphasis in pilot areas now comprises I 7 such areas is being placed on infant morbidity and the in I 3 countries. A number of experimental quality of care. As regards the nutrition of programmes in different parts of the Region children and adolescents, the trends in the at the end of the biennium provided a industrialized countries are towards new convincing practical demonstration that, forms of malnutrition, often characterized given the determination, comprehensive by overnutrition. Furthermore air pol­ community mental health care could be lution, the use of food additives, and over­ achieved without any large financial medication are leading to chronic diseases expenditure. in children (cancer, allergies, respiratory I 5. I I 6 The sharp increase since I 9 5o diseases) and new patterns of morbidity are in the consumption of alcohol in countries emerging. of the Region was accompanied by an I 5• I I 3 The Conference on the Child increase in the range of related medical and the Adolescent in Society (Athens, and social problems. The participants at a September I 978) recommended inter alia conference on public health aspects of guidelines for establishing standards of alcohol and drug dependence (Dubrovnik, growth and development, well-defined con­ Yugoslavia, I978) were unanimous in ditions for the treatment of chronically ill advocating that all known measures should children, increased interaction between be taken to limit the consumption of families, schools and society, and a new alcohol and illicit drugs. approach to health education for children and adolescents.1 These recommendations Prop~lactic, diagnostic and therapeutic sttbstances 1 World Health Organization. The child and the ado­ leuenl in society. Report on a WHO conference. I 5. I I 7 Emphasis in this programme is Copenhagen, 1979 (EURO Reports and Studies, No. 3). shifting away from the organization of

224 REGIONAL TRENDS national drug control agencies towards but also from international organizations the more general area of drug policies and and the Arab countries was invaluable in management, concerned mainly with ensuring the provision of supplies and disseminating information and coordinat­ equipment at the crucial time. UNDP is ing the work of producers, prescribers, and financing a project to ensure coordination consumers of drugs, and of the authorities between neighbouring countries to pre­ responsible for legislation, registration and vent the spread of the disease. control. The publication Studies in Drug Utilization 1 describes how with relatively I5.I2o The new trans-Saharan high­ modest means it is possible to collect and way will intensify traffic in that part of the analyse a great deal of data on the prescrib­ Region and as mobility increases, so will ing habits of physicians, the side effects the risk of transfer of communicable of the drugs they prescribe, and the extent disease. The Algerian Government, in to which patients follow their instructions. cooperation with the Regional Office and Its conclusion is that there is a pressing UNDP, has therefore launched a project need for a greater number of more extensive to obtain technical advice and to facilitate studies on drug utilization. the specialized training inter alia of micro­ biologists, parasitologists and epidemio­ logists. The final objective is a system of Disease prevention and control epidemiological surveillance. I 5. I I 8, As regards communicable diseases the situation in the Region remains I 5• I 2 I The need has been apparent unstable, in large measure because of the for some years for simple guidelines for ever-increasing volume of international the management of sexuai!J transmitted travel and of trade in food and animal diseases by physicians in general practice, feeds. Enterobacterial infections, viral covering the best use of available laboratory hepatitis, and respiratory virus infections facilities and the search for the source of are the major causes for concern, followed infection and for those to whom it may by sexually transmitted diseases, tuber­ have been passed. The Regional Office culosis, and wildlife rabies. published a comprehensive guide for general practitioners in I 979. 2 5. I I 9 There was a significant fall in the total number of malaria cases detected in I 5. I 22 The cardiovascular disease control Turkey: in the first nine months of I979 programme, which advocates the com­ there was a decrease of about 70% as munity approach, was evaluated in I978. compared with the same period in I978 The most promising objective in preven­ (24 744 cases as against 82 IIo). The tion is now considered to be the linking number of cases in I 977 was I 15 5 I 2 and and coordinating of national efforts in in I978 (whole year), 87 867. In the pilot areas without the need for any new <;ukurova Plain the decrease was So%, but WHO studies. Priority tasks will be to the situation in the centre (Adana) of the train staff in comprehensive community area most at risk is still serious. Aid not control programmes, establish information only from other countries of the Region systems for services and research in the

1 Bergman, U. et al., ed. Studies in drug utilization. 2 Willcox, R. R. The management of sexually transmitted Methods and applications. Copenhagen, World Health diseases. A guide for the general practitioner. Copenhagen, Organization, 1979 (WHO Regional Publications, World Health Organization, 1979 (EURO Reports European Series, No. 8). and Studies, No. 12).

225 THE WORK OF WHO, 1978--1979 major chronic diseases, and maintain proper in daily life-in pesticides, drugs, food channels for the distribution of information additives, industrial chemicals, fuels, and supplied by WHO. chemical consumer products. Many of these chemicals appear in the working I5.I23 An analysis of mortality from environment, or in water, food and soil, ischaemic heart disease in the European as pollutants resulting from the wastes of Region shows that in the majority of production and consumption. Between countries there is no change, or only a 200 and 1000 new chemicals are put on the very slight one, in age( sex-specific mortality market every year. The considerable public rates. The only three countries showing a concern at the adverse effects some of these small but consistent decrease in mortality chemicals may have on human health and in the population under sixty-five years of on the environment is offset by the many age are Belgium, Finland, and Norway. benefits derived from their use. Moreover the chemical industry is a very significant I 5. I 24 Rheumatic diseases were the sub­ factor in national economics and inter­ ject of the Technical Discussions at the national trade, and about half the total twenty-eighth session of the Regional world trade is within the European Region. Committee (I978). The total economic burden resulting from permanent and I 5. I 2 7 Accidental exposures of epi­ transient disability due to rheumatic diseases demic proportions have occurred during in the working population is immense and the last few years in several countries, goes well beyond the cost of providing following industrial accidents or the release the relevant medical care and social services. of toxic chemicals into the environment, One aspect of the regional programme is either in products or as wastes. However to promote the training of rheumatologists perhaps the greatest concern relates to the in the use of epidemiological methods. effects of chronic long-term exposure to chemicals, whether at the place of work or I 5. I 2 5 A publication issued in I 979 1 in the general environment. In I 978 consists of a general review of oral health therefore a programme on environmental care in Europe with a country-by-country toxicology was started in the Region, to description of national oral health services, complement WHO's long-standing global their origins, organization and problems. programme. A consultation on manpower It also examines the basic features of a development in toxicology was held and a practical model for such services, including project to be financed by UNDP was drawn the use of dental auxiliaries. The main up. It is expected that ten Member States emphasis of the new programme will be on of the Region will participate. The new prevention. programme will be developed within the framework of the international programme on chemical safety (see Chapter I I, para­ Promotion of environmental health graphs II.9-II.II).

I 5. I 26 Some four million chemicals have been isolated from natural products I 5. I 28 WHO assisted ECE in preparing or synthesized and about 6o ooo are used the Convention on Long-Range Trans­ boundary Air Pollution and the Regional Director for Europe represented the 1 Kostlan, J. Oral health services in Europe. Copen­ Director-General at the signing of the hagen, World Health Organization, 1979 (WHO Regional Publications, European Series, No. 5). Convention in November I979·

226 REGIONAL TRENDS

I 5. I 29 In preparation for the publica­ continuing education should be controlled tion of new WHO standards for drinking­ and organized by appropriate bodies in the water in I98I, which is being undertaken same way as undergraduate and post­ by the Regional Office, a series of working graduate training are controlled and admin­ groups was convened during the biennium istered by academic and other bodies. (see Chapter II, paragraph IL34) It should be an integral part of employment and not simply a means of professional I 5. I 30 Foodborne diseases appear to be advancement. It should moreover take on the increase in the Region. Only a small place in the widest possible range of hos­ proportion of the total number of cases are pitals, clinics and practices and should be ever reported, yet such diseases are prob­ adequately budgeted for. The Technical ably the second largest cause of morbidity Discussions at the twenty-ninth session of in Europe. Mass catering is on the increase, the Regional Committee developed this and experience shows that most foodborne theme, stressing that continuing education disease is caused not by the industrial pro­ must be seen as embracing all the health duction of food but by its preparation professions and not only the senior levels. in institutions, catering establishments, and It was pointed out that there were great the home. The main causes are contami­ advantages in bringing together health nation of raw materials or equipment, cross­ professionals from different backgrounds. contamination during preparation, inade­ Work in this field benefits greatly from quate refrigeration or heating, and poor cooperation with the Association of Schools personal hygiene. of Public Health in the European Region and the Association for Medical Education I 5. I 3 I Work continued during the in Europe. biennium on the establishment of a sur­ veillance programme for the control of Publications foodborne infections and intoxications. A survey describing food legislation and I 5. I 3 3 The Regional Office continued food control administration methods is its publications programme in order to being prepared. UNDP is financing a develop further the exchange and dissemi­ project in Turkey and also an intercountry nation of information. The reports on meet­ project in food safety services, with ings and studies were included in a special emphasis on mass catering, information series-BUBO Reports and Studies-which, on food safety, and food regulations. together with Public Health in Europe, is now on sale and widely distributed. The number of requests for these publications Health manpower development has steadily increased.

I 5. I 32 The growing interest in con­ I 5. I 34 The Regional Office entered tinuing education is reflected in the large into a number of agreements with well­ number of courses organized by national known commercial publishers and national or by private professional initiative through­ institutes wishing to translate such material out Europe, and also in the studies and and issue it in languages other than WHO's meetings conducted by the Regional Office. working languages, an extension of the A working group on the continuing edu­ practice by which health authorities produce cation of health personnel as a factor in versions of Regional Office publications in career development recommended that their national languages.

227 THE WORK OF WHO, 1978-1979

Eastern Mediterranean Region orative activities that would formerly have been carried out by international staff. 15·I35 The years I978-I979, in the Eastern Mediterranean Region as elsewhere, 15·I38 WHO's own utilization of were the first in which the Organization national expertise from within the Region had a specific social target for its work. also expanded considerably. The regional All activities in the Region were strongly advisory panels were previously few in influenced by the commitment inherent number ; they tended to be relatively in the decision to adopt the social target inactive in the sense that their members of health for all by the year zooo. Since contributed to the work of WHO only all governments explicitly or implicitly through infrequent meetings. They now accepted that target, it was necessary for represent a well-utilized resource of skilled both the Organization and the Member technical advisers and collaborators, I 54 States to do some substantial rethinking in number, an increasing proportion of during the biennium as to what are its full whom are in regular correspondence or implications. other contact with the Regional Office. Their work ranges from the ad hoc pro­ 15. I 36 Two meetings of major signifi­ vision of advice-written or otherwise­ cance, one global and one regional, helped on a particular problem or project, to greatly to focus such rethinking. One continuous active collaboration in a form was the Alma-Ata Conference, at which that makes them almost part-time staff the countries of the Region were well members, even though there is no employer/ represented and where the important devel­ employee relationship with WHO. opments in certain of them-especially the achievements of Iran and Sudan in pri­ I 5. I 39 Another important example of mary health care-were very much to the increased collaboration with Member States fore. The other was the regional Ministerial and their nationals has been the setting up Consultation on Health Services and Man­ by the Regional Committee of two impor­ power Development (Teheran, I978),' tant committees : the Regional Consultative which was dedicated to matching more Committee, and the Ad Hoc Committee closely the education and training of per­ on the Study of WHO's Structures in the sonnel to the real needs of the health light of its Functions. In addition, the services. 1 Since that Consultation, a large Regional Director appointed a group of number of countries have taken very high-level experts to constitute the regional definite steps towards coordinating if not Health Development Advisory Committee, integrating their health services and man­ which is scheduled to hold its first meeting power development programmes. during the second quarter of I 980. It is expected that the work of the Regional Utilization of national expertise Consultative Committee will expand and will grow in significance. The study of I 5. I 37 A great deal was done during WHO's structures in the light of its func­ the biennium to increase the effective tions will continue for at least a further year. mobilization of national human resources for work in collaboration with WHO. Interagenry collaboration and technical Nationals of Member States were recruited cooperation among developing cottntries to perform tasks within WHO's collab- 15·I40 Trends in the United Nations 1 See Chapter rz, paragraph r2.r8. system are towards a more integrated

228 REGIONAL TRENDS approach on the part of agencies, and a which dates from the first session of the further study of the implications this will regional Advisory Committee on Medical have for the Region is planned. Research in I 976. In this, as in the bio­ medical research programme as a whole, 15 ·14 I It was very gratifying during the emphasis is on developing national the biennium to see the increasing number capabilities for research, both human and of activities taking place in the spirit of institutional. technical cooperation among developing countries. This is an approach that has I5.I45 The research programme cuts long been familiar in the Region, and good across the boundaries of several other pro­ examples of it continue to multiply. Since grammes, and useful projects in drug utiliza­ the countries making up the Region are tion, control of diarrhoeal diseases, and so diverse, there are many opportunities various aspects of health manpower for one country to offer some of its surplus development were continued. of manpower, expertise or financial resources to cover the deficits occuring in Health manpower development another. I 5. I46 Three studies in health man­ power development were started during International Year of the Child I979-on oral health manpower, environ­ I 5. I 42 I 979 was the International Year mental health manpower, and quality of of the Child and a particularly suitable year nursing services. All three are at an early in which to report the promising start of stage but they may be examples for similar the expanded programme on immunization. work in the future. An appreciable number of countries were 15. I 4 7 One significant landmark was already beginning to make substantial the first health services orientation course inroads on the six preventable diseases (Alexandria, January I979), which was an that the programme was designed to attack. initial step towards building up a cadre of Much remains to be done if the targets set workers in this field. for I 990 are to be met in the Region, but this is a programme in which there is visible Primao· health care progress and in which the countries con­ cerned are showing enthusiasm in their 15.148 As was reported to the Alma­ collaboration with WHO. Ata Conference, the primary health care concept found ready acceptance in the coun­ I 5. I43 Another significant feature of tries of the Region. It should be noted that the International Year of the Child was a in Sudan, where some of the earliest work series of visits by consultants, mostly in primary health care was carried out, internationally known paediatricians. They considerable thought was given in I 979 to reviewed the progress in child health working out appropriate methods for matters in nine countries and made recom­ evaluating the effect of the programme mendations on future health services for to date. children. Promotion of environmental health Research promotion and development I 5. I49 In the Eastern Mediterranean I 5. I44 Research continued to be Region, as elsewhere, environmental health focused on applied health services research, problems, exacerbated by the rapid popu- THE WORK OF WHO, 1978--1979 lation growth still taking place in almost considerable proportion of staff time. In the all countries, become more serious each latter part of I979 considerable effort was year. During I978-I979 special efforts devoted to evolving an integrated approach were made to take a more up-to-date and to programme development and manage­ long-term approach to this subject. At the ment which, while providing WHO and end of the biennium a team of engineers its Member States with streamlined pro­ was engaged, along with national personnel gramming mechanisms and effective mana­ of Member States, in working out the gement tools, could still be carried out with framework for an integrated regional the somewhat limited numbers of senior environmental health programme. Initial staff at all levels both within WHO and in studies were made on the feasibility of a the ministries of health of Member States. regional centre for environmental health activities. Western Pacific Region Programme development I 5. I 53 The guiding principles endorsed I 5. I 5o A good deal of work went into by the Health Assembly for the use of the preparation of further medium-term Member States in formulating their strat­ programmes. The tendency has been to be egies for the attainment of health for all by somewhat critical of the approach so far the year 2ooo were an invitation to coun­ adopted. In the one area where a medium­ tries to draft long-term plans that would term programme had been in operation serve as the framework for successive since its submission to the Regional Com­ medium-term plans whose cumulative mittee in I977, it proved useful for the impact would enable them to reach that monitoring and evaluation of the inter­ goal. For that reason, interest in one of country part of the programme. Never­ these strategies, country health program­ theless, the general view in the Region is ming, increased considerably during the that future medium-term programmes biennium and can be expected to gain should go no farther than setting targets in momentum. WHO in the Western Pacific simple terms and listing the types of activity Region must prepare itself for requests for in which WHO can offer cooperation with collaboration that require a multi-disci­ Member States. plinary approach. It will also be necessary to develop regional capability at existing I 5. I 5I During the formulation of several of the medium-term programmes institutions by providing training in coun­ particular emphasis was laid on consul­ try health programming and management, tation with countries. In the large com­ and by conducting research in that field. municable disease control programme, for Some of these institutions may be able to example, visits for this purpose to almost meet the needs of other countries, within all countries of the Region, along with a the framework of technical cooperation series of meetings, made possible the most among developing countries, and eventually intensive consultations so far achieved. It be regarded as part of the regional health is hoped that this will be reflected in a more development network. realistic medium-term programme than could otherwise have been developed. Health information

I 5. I 52 Information and management 15. I 54 The design, development and matters generally continued to occupy a establishment of · efficient and dynamic REGIONAL TRENDS health management information systems to respond more realistically to needs. continue to be a priority. In health stat­ Research into the allocation of resources to istics, appropriate indicators for planning, the peripheral health services, including programming, monitoring and evaluation resources for primary health care, is there­ are being developed. fore one of the main priorities. The role of technology in the health services, Research promotion and development particularly the relevance of high-cost technology, must also be examined. I 5. I 5 5 Research promotion and develop­ ment are expanding. Two intercountry I 5. I 58 Another task for WHO in the programmes, at present in the early stages, Region will be to assist in rationalizing should be important in establishing pri­ primary health care activities and training orities : the regional centre for research the necessary manpower. Training processes and training in tropical diseases at the are required that are suited to adult health Institute for Medical Research, Kuala workers with little formal schooling, who Lumpur, and the programme of surveil­ will in effect be the catalysts of the new lance for acute respiratory infections at type of health system. In this, as in the Goroka (Papua New Guinea). These two implementation of primary health care, programmes should moreover strengthen developments in one country will have an national research capabilities and the con­ important effect on those in other countries. cept of technical cooperation among devel­ Training courses, based on experience oping countries. acquired from research programmes, will be implemented within the context of I 5. I 56 Countries are being encouraged technical cooperation among developing to establish national research councils, and countries. The exchange of information and to promote career structures in research. the number of study tours, seminars, and The network of collaborating centres in workshops should increase, participants the Region is being extended, as also the coming not only from within the Region exchange of scientists in several fields. but also from other regions. These activities are intended to facilitate the exchange of information and inter­ I 5. I 59 The improvement of health lab­ country collaboration ; they will also oratory services is directed : (I) to develop­ facilitate health services research. Research ing techniques and training personnel for training grants, contracts for collaborative such services as delivered through primary research, and meetings continue to be health care, with emphasis on the tech­ important tools in the management of the nology appropriate to the country; (z) to programme. instituting training and facilities at the intermediate level, particular attention being Health services development given to supervision, monitoring, logistics, and middle-level technology; (3) to pro­ I 5. I 57 The trend in the Region is moting management and quality control towards expanding research and develop­ at national level. ment activities that will help governments to extend health care coverage. Reorienta­ I5.I6o As the result of a resolution tion of basic health services in support adopted by the Regional Committee in of primary health care started in I 977 and I978/ activities in relation to workers' the knowledge acquired from health ser­ 1 vices research should enable those services Resolution WPR/RCZ9.RI4. THE WORK OF WHO, 1978--1979

health have increased, and the reactions policies, and on nutritional work within of a number of countries suggest that more the health sector, particularly in the context requests may be expected for collaboration of primary health care. Progress has been in occupational health programmes. made with nutrition surveillance systems in several countries. National training Fami!J health facilities have been reinforced by the institution of two regional training courses. I 5. I 6 I Studies on the "risk approach" However, difficulties still subsist and in maternal and child health care will are primarily due to the conflicting continue. Data collected in Malaysia are interests of the different sectors and to an being analysed as the first phase in formu­ inadequate data base. Future emphasis lating a strategy based on this concept. It is must be on the establishment of at least a hoped that the results of experience in minimum nutrition component in primary Malaysia can be applied elsewhere in the health care and on operational research to Region. find the most effective and suitable method for delivering such a programme at com­ I 5. I 6z Many countries are showing munity level. interest in the special problems and health needs of adolescents. A working group will be held in March I98o to examine the prob­ Mental health lems related to sexuality, unwanted preg­ I 5. I 6 5 The expanding community nancies, drug abuse, and delinquency and mental health programme warranted the to discuss the need for counselling. The establishment of a regional coordinating fact that in most countries adolescents have group as an advisory body to the Regional hitherto been largely ignored will open Director. At its first meeting (April I979), many areas of collaboration for WHO. it recommended the formation of national

I 5. I 6 3 Considerable advances were coordination groups ; the designation of made in fami!J planning in the last ten years, collaborating centres for research and train­ and the maternal and child health pro­ ing in mental health ; the strengthening of grammes of most countries or areas in the research ; and the training of health per­ Region contain a family planning com­ sonnel in mental health. ponent. Nevertheless, there are still a number of problems connected with the Proprylactic, diagnostic and therapeutic methodology of fertility regulation, delivery substances of services, and effective use of contra­ ceptives. The regional seminar on new I 5. I 66 Within the programme on pro­ developments in fertility regulation held phylactic, diagnostic and therapeutic sub­ late in I977, was followed up by a sub­ stances, intercountry activities on drug regional seminar on the same subject (Suva, policies and management and on pharma­ December I979)· Collaboration with ceuticals will be expanded, collaboration Member States in developing service­ continuing in particular with governments oriented research in fertility regulation in the South Pacific area, where a joint and in building up national research capa­ pharmaceutical service is proposed (see bilities will continue. Chapter 8, paragraph 8.12). Elsewhere in the Region, WHO will collaborate in I 5. I 64 In nutrition the emphasis is on studies of pharmaceutical supply systems. development of national food and nutrition Evaluation of the therapeutic properties REGIONAL TRENDS and the efficacy of medicinal plants will case-detection, treatment, and the training continue, together with the dissemination of health personnel, combined with and application of existing knowledge. activities to encourage the community to accept leprosy patients. Disease prevention and control I 5. I 7 I With the promotion of the I 5. I 67 Activities, most of which include expanded programme on immunization, a research component, are being intensified BCG vaccination will become more signifi­ in relation to diarrhoeal diseases, sexually cant in tuberculosis control. Case-detection transmitted diseases, acute respiratory and through sputum examination is being arbovirus infections, schistosomiasis, fila­ intensified and emphasis continues to be riasis, leprosy, tuberculosis and malaria. placed on domiciliary care, training of health personnel, and integration of tuber­ I p68 As part of the epidemiological culosis control work into the general health surveillance and information system, efforts services. are being made to strengthen the reporting system for notifiable diseases and the I 5. I 7 2 In the malaria action programme relaying of information. A study of train­ new approaches are being developed and ing in epidemiology in the Region revealed established ones strengthened. They include certain deficiencies which it is hoped will responsibility by the community for spray­ be corrected through a general improve­ ing operations, coordination of measures ment in training. Statistical and laboratory between countries, manpower development, support for epidemiological services are and research on some of the administrative being developed. and technical problems encountered, the latter particularly in relation to the emer­ I 5. I 69 The short-term approach to the gence of resistant strains of Plasmodium control of diarrhoeal diseases resides in the falcipamm, and the resistance of certain use of oral rehydration salts, combined vectors to insecticides. A notable achieve­ with education in elementary personal ment with regard to drug resistance was the and food hygiene, the promotion of breast­ production in the Philippines of in vitro test feeding, and good nutrition. Sexttai!J kits. transmitted diseases continue to be a problem, particularly dissemination of ~-lactamase­ I 5. I 7 3 With respect to cancer, the producing strains of Neisseria gonorrhoeae. measures being taken include development Potential collaborating centres for research of cancer registries, epidemiological studies have been identified and national control of causative factors, and community-based programmes are being strengthened. control programmes. Further studies are Guidelines for the control of dengue and being undertaken on metabolic disorders. dengue haemorrhagic fever are being Community control programmes for car­ revised and a project has been established diovascular diseases, particularly hypertension for the institution of emergency measures and rheumatic heart diseases, are being should epidemics occur. extended.

I 5. I 70 In lepro!J, where dapsone resist­ I 5. I 7 4 Dentists in the Region are ready ance has caused concern, a new drug regi­ to delegate repetitive work to auxiliaries, men combining dapsone and rifampicin and to utilize the services of health workers or clofazimine is being introduced. and schoolteachers for preventive pro­ Emphasis will continue to be placed on grammes in oral health. A course in public THE WORK OF WHO, 1978-1979 health dentistry (I979) enabled participants national level and a corresponding com­ from I7 countries to acquaint themselves mitment in financial support and man­ with the activities planned under the power. Such an approach is being stimu­ regional medium-term programme in oral lated by individual projects in a number of health. The Dental Research Unit, Medical countries and by the Global Environmental Research Council, Wellington, was desig­ Monitoring System (GEMS), under which nated a WHO collaborating centre for collection of data began in I978 in the air research in dental caries and periodontal monitoring programme and in I 979 in the disease. Self-instructional programmes are water quality monitoring programme. being developed for dental personnel and national seminars have proved to be Health manpower development effective. I 5. I 7 8 More than any other programme health manpower development is dependent Promotion of environmental health on general socioeconomic development. I 5.17 5 In environmental health WHO The wider access to primary and secondary is collaborating in an ever-broadening education in all countries should mean that range of activities. The regional centre for students entering the health professions the promotion of environmental planning will be better prepared, and should result and applied studies at the University of in some modification of existing curricula, Agriculture (University PertanianMalaysia), particularly for middle- and basic-level Kuala Lumpur, became operational in health workers (at present an inordinate January I979· Activities include the pro­ proportion of the syllabus for such workers vision of specialized consultant services, is devoted to general studies). and manpower development through group educational meetings and training courses. I5.I79 Member States have begun to Assessment of environmental impact and take a greater interest in the planning of environmental planning (including protec­ health manpower, either in isolation or as tion programmes for water and air) are a follow-up to country health program­ receiving greater attention. ming. This interest has been accelerated by the world economic recession, which has I 5. I 76 Regional activities have led to driven countries to improve the cost­ an increased capability for planning and effectiveness of their investment in health influencing rural and urban programmes, manpower. Furthermore, changes in with a resultant increase in water supply United States legislation on immigration and sewerage facilities. There is a growing of trained health manpower, particularly interest in pre-investment studies, some of physicians and nurses, have closed a major which have attracted bilateral aid or support outlet for health professionals from develop­ from international development banks. ing countries ; in the Western Pacific Region Rapid assessment reports on drinking­ the same policy is being followed by Aus­ water supply and sanitation have been tralia and New Zealand. These develop­ completed for nine countries and will ments have had their effect on health man­ provide a basis for the programme in the power planning. International Drinking-Water Supply and Sanitation Decade. I 5. I So If the present trend continues, most countries or areas should soon have I 5. I 77 Strong environmental protection medical assistants or nurse practitioners as programmes require a broad approach at intermediaries between the peripheral health REGIONAL TRENDS services and tertiary health care. The newly ability to apply the knowledge acquired, developed training programmes for such are being used to an increasing extent. workers have, in many instances, utilized Unfortunately however the place of the systematic educational planning approaches, medical educator within the academic beginning with task analysis. It should be hierarchy is only slowly being recognized possible eventually to study the functions and there is still some hesitancy, on the part of other health workers, thus permitting a of physicians in particular, to take up such more logical distribution of duties between a career. the various categories and avoiding much of the present duplication of skills. I 5. I 8 3 These developments have been exc1tmg and significant but there is still I 5• I 8 I Continuing education is increas­ room for closer collaboration between the ingly seen as an integral part of the career various agencies concerned with the pro­ of a health worker. Maintenance of stan­ duction of health manpower and its utiliza­ dards of performance-the real justification tion, and this will be a major issue in for continuing education-will not be easy developing strategies for achieving the to attain, but several countries of the Region goal of health for all by the year zooo. intend to establish systems for monitoring Wider opportunities for gaining multi­ the performance of physicians. professional educational experience are also needed. I 5. I 8 z It is now accepted that teachers of health personnel themselves have to be I 5. I 84 Although the fellowships pro­ trained in teaching methods. Educational gramme will continue, as an important processes to ensure that suitable students way of developing national health man­ are selected, and evaluation methods to power, training is expected to take place check that students are learning what they to an increasing extent within the countries are supposed to learn and to assess their themselves.

Annex 1

Members and Associate Members of the World Health Organization

at JI December I979

At 31 December 1979 the World Health Organization had I 52 Member States and two Associate Members. They are listed below with the date on which each became a party to the Constitution or the date of admission to associate membership.

Afghanistan I9 April I948 Democratic Yemen 6 May I968 Albania 26 May I947 Denmark* I 9 April I 948 Algeria* 8 November I962 Djibouti IO March I978 Angola I5 May I976 Dominican Republic 2I June I948 Argentina * 22 October I948 Ecuador* I March I949 Australia 2 February I948 Egypt* I6 December 1'947 Austria * 30 June I947 El Salvador 22 June I948 Bahamas* I April I974 Ethiopia I I April I947 Bahrain 2 November I97I Fiji* I January I972 Bangladesh I9 May I972 Finland* 7 October I947 Barbados* 25 April I967 France I6 June I948 Belgium* 25 June I948 Gabon 2I November I96o Benin 20 September I96o Gambia* 26 April I 97I Bolivia 23 December I949 German Democratic Republic * 8 May I973 Botswana 26 February I975 Germany, Federal Republic of* 29Mayi95I Brazil * 2 June I948 Ghana* 8 April I957 Bulgaria * 9 June I948 Greece* I2 March I948 Burma I July I948 Grenada 4 December I974 Burundi 22 October I962 Guatemala* 26 August I 949 Byelorussian SSR 7 April I948 Guinea* I9 May I959 Canada 29 August I946 Guinea-Bissau 29 July I974 Cape Verde 5 January I 976 Guyana* 27 September I966 Central African Republic * 20 September I 960 Haiti* I2 August I947 Chad I January I96I Honduras 8 April I949 Chile* 15 October I948 Hungary* I7 June I948 China* 22 July I946 Iceland I7 June I948 Colombia I4 May I959 India* I 2 January I948 Comoros 9 December I975 Indonesia* 23 May I950 Congo 26 October I96o Iran* 23 November I946 Costa Rica I 7 March I 949 Iraq* 23 September I947 Cuba* 9 May I950 Ireland * 20 October I947 Cyprus* I6 January I96I Israel 2I June I949 Czechoslovakia * I March I948 Italy II April I 94 7 Democratic Kampuchea * 17 May I950 Ivory Coast * 28 October I96o Democratic People's Republic of Jamaica* 2 I March I 963 Korea I9 May I973 Japan* I6 May I95I

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

237 THE WORK OF WHO, 1978--1979

Jordan * 7 April I947 Saudi Arabia 26 May I947 Kenya* 27 January I964 Senegal* 3 I October I 960 Kuwait* 9 May I96o Seychelles I I September I 979 Lao People's Democratic Republic* I7 May I950 Sierra Leone * 20 October I 96 I Lebanon I9 January I949 Singapore* 2 5 February I 966 Lesotho* 7 July I967 Somalia 26 January I96I Liberia I4 March I947 South Africa 7 August I947 Libyan Arab Jamahiriya * I6 May I952 Spain* 28 May I95I Luxembourg * 3 June I949 Sri Lanka 7 July I948 Madagascar * I6 January I96I Sudan I4 May I956 Malawi* 9 April I965 Suriname 25 March I976 Malaysia* 24 April I958 Swaziland I6 April I973 Maldives* 5 November I965 Sweden* 28 August I947 Mali* I7 October I 960 Switzerland 26 March I947 Malta* I February I965 Syrian Arab Republic I8 December I946 Mauritania 7 March I96I Thailand* 26 September I947 Mauritius* 9 December I968 Togo* I3 May I96o Mexico 7 April I948 Tonga* I4 August I975 Monaco 8 July I948 Trinidad and Tobago * 3 January I963 Mongolia* I 8 April I962 Tunisia* I4 May I956 Moroc= * I4 May I956 Turkey 2 January I948 Mozambique I I September I975 Uganda 7 March I963 Nepal* 2 September I95 3 Ukrainian SSR 3 April I948 Netherlands * 25 April I947 Union of Soviet Socialist New Zealand * IO December I946 Republics* 24 March I948 Nicaragua* 20 April I95o United Arab Emirates 30 March I972 Niger* 5 October I96o United Kingdom of Great Nigeria* 25 November I96o Britain and Northern Ireland * 22 July I946 Norway* I8 August I947 United Republic of Cameroon 6 May I96o Oman 28 May I97I United Republic of Tanzania * I5 March I962 Pakistan* 23 June I948 United States of America 2I June I948 Panama 20 February I95 I Upper Volta * 4 October I 960 Papua New Guinea 29 April I 976 Uruguay* 22 April I949 Paraguay 4 January I949 Venezuela 7 July I948 Peru I I November I 949 VietNam I7 May I950 Philippines * 9 July I948 Yemen 20 November I95 3 Poland* 6 May I948 Yugoslavia * I9 November I947 Portugal I 3 February I 948 Zaire* 24 February I 96 I Qatar II May I972 Zambia* 2 February I965 Republic of Korea * I7 August I949 Romania* 8 June I948 Associate Members Rwanda* 7 November I962 Samoa I6 May I962 Namibia I6 May I974 Sao Tome and Principe 23 March I976 Southern Rhodesia 1 I6 May I950

* Member States that have acceded to the Convention on the Privileges and Immunities of the Specialized Agencies and its Annex VII. I Southern Rhodesia's associated membership-was regarded as being in suspense. Annex 2

Organizational and Related Meetings

I. Meetings in I9JS Executive Board, sixty-first session Geneva, I I-26 January Executive Board : Standing Committee on Nongovernmental Organizations Geneva, 17 January Executive Board : Working group on the organizational study on the role of WHO Geneva, 20 January, expert advisory panels and committees and collaborating centres in meeting 26-29 June, and the needs of WHO regarding expert advice and in carrying out technical 2-3 November activities of WHO Executive Board : Ad Hoc Committee on Drug Policies Geneva, 23 January, 3-~ May Executive Board : Ad Hoc Committee on Malaria Geneva, 2~ January·and I6 May World Health Assembly: Special committee of experts to study the health con­ Geneva, 26-28 April ditions of the inhabitants of the occupied territories in the Middle East Executive Board : Committee to Consider Certain Financial Matters Prior to the Geneva, 8 May Health Assembly Thirty-first World Health Assembly Geneva, 8-24 May Executive Board, sixty-second session Geneva, 2~-26 May Executive Board : Programme Committee (preparatory meeting) Geneva, 26 May Regional Committee for the Western Pacific, twenty-ninth session Manila, 2I-2~ August Regional Committee for South-East Asia, thirty-first session Ulan Bator, 22-28 August Regional Committee for Europe, twenty-eighth session London, I9-23 September Regional Committee for Africa, twenty-eighth session Kigali, 2o-27 September Regional Committee for the Americas, thirtieth session/XX Pan American Sanitary St George's (Grenada), Conference 2~ September-~ October Regional Committee for the Eastern Mediterranean, twenty-eighth session, Sub­ Manama (Bahrain), Committee A ~I2 October Executive Board, Programme Committee Geneva, 6-Io November

2. Meetings in I979

Executive Board: Programme Committee Geneva, 8-9 January Executive Board, sixty-third session Geneva, I0-26 January Executive Board : Working group on the organizational study on the role of WHO Geneva, I I-I~ January expert advisory panels and committees and collaborating centres in meeting Bangkok, 29-3 I March and in carrying out technical activities of WHO Geneva, I I-12 May and .7.4-27 July Executive Board : Standing Committee on Nongovernmental Organizations Geneva, I6 January Executive Board: Working group on the organizational study on the role of WHO Geneva, I9 January in training in public health and health programme management, including and I6 May the use of country health programming Executive Board : Committee to Consider Certain Financial Matters Prior to the Geneva, 7 May Health Assembly Thirty-second W odd Health Assembly Geneva, 7-.z ~ May Regional Committee for the Eastern Mediterranean, special session, Sub-Committee A Geneva, I2 May Executive Board, sixty-fourth session Geneva, 28-29 May Executive Board : Programme Committee (preparatory meeting) Geneva, 29 May Executive Board: Working group to study the question of the transfer of the Geneva, .7.9 May and Regional Office for the Eastern Mediterranean 24-2~ July Alexandria, 26-q September

2 39 THE WORK OF WHO, 1978-1979

World Health Assembly: Special committee of experts to study the health con­ ditions of the inhabitants of the occupied territories in the Middle East Geneva, I9-20 July Regional Committee for Europe, twenty-ninth session Helsinki, II-I5 September Regional Committee for South-East Asia, thirty-second session New Delhi, I 8-24 September Regional Committee for Africa, twenty-ninth session Maputo, I9-26 September Regional Committee for the Americas, thirty-first session/XXVI Meeting of the Washington, 24 September- Directing Council of P AHO 5 October Regional Committee for the Western Pacific, thirtieth session Singapore, 2-8 October Regional Committee for the Eastern Mediterranean, twenty-ninth session, Sub­ Doha (Qatar), Committee A 8-I I October Executive Board : Programme Committee Geneva, I9-23 November

Annex 3

Intergovernmental Organizations that have entered into rormal Agreements with WHO approved by the World Health Assemb!J, and Nongovernmental Organizations in 0 jficial Relations with WHO

at }I December I979

I. Intergovernmental organizations

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

2. Nongovernmental organizations

African Medical and Research Foundation Inter- International Association for the Study of the Liver national International Association of Environmental Mutagen Biometric Society Societies Christian Medical Commission International Association of Logopedics and Phoniatrics Commonwealth Medical Association International Association of Medical Laboratory Council for International Organizations of Medical Technologists Sciences International Association of Microbiological Societies European Society for Clinical Investigation International Association for Suicide Prevention Inter-American Association of Sanitary and Environ- International Association on Water Pollution Research mental Engineering International Astronautical Federation International Academy of Pathology International Brain Research Organization International College of Surgeons International Agency for the Prevention of Blindness International Commission on Radiation Units and International Air Transport Association Measurements International Association for Accident and Traffic International Commission on Radiological Protection Medicine International Committee of Catholic Nurses International Association of Agricultural Medicine and International Committee of the Red Cross Rural Health International Confederation of Midwives International Association of Cancer Registries International Council on Alcohol and Addictions International Association for Child and Adolescent International Council on Jewish Social and Welfare Psychiatry and Allied Professions Services ANNEX 3

International Council for Laboratory Animal Science International Society of Radiographers and Radio- International Council of Nurses logical Technicians International Council of Scientific Unions International Society of Radiology International Council on Social Welfare International Sociological Association International Solid Wastes and Public Cleansing International Council of Societies of Pathology Association International Cystic Fibrosis (Mucoviscidosis) International Union of Architects Association International Union of Biological Sciences International Dental Federation International Union against Cancer International Diabetes Federation International Union for Child Welfare International Electrotechnical Commission International Union for Conservation of Nature and International Epidemiological Association Natural Resources International Ergonomics Association International Union for Health Education International Federation of Clinical Chemistry International Union of Immunological Societies International Federation of Fertility Societies International Union of Local Authorities International Federation of Gynecology and Obstetrics International Union of Nutritional Sciences International Federation of Health Record International Union of Pharmacology Organizations International Union of Pure and Applied Chemistry International Federation for Housing and Planning International Union of School and University Health International Federation for Information Processing and Medicine International Federation for Medical and Biological International Union against Tuberculosis Engineering International Union against the Venereal Diseases and International Federation of Medical Srudent the Treponematoses Associations International Water Supply Association International Federation of Multiple Sclerosis Societies Joint Commission on International Aspects of Mental International Federation of Ophthalmological Societies Retardation International Federation of Pharmaceutical Manu- League of Red Cross Societies facturers Associations Medical Women's International Association International Federation of Physical Medicine and Permanent Commission and International Association Rehabilitation Population Council on Occupational Health International Federation of Sports Medicine Rehabilitation International International Federation of Surgical Colleges World Association of Societies of (Anatomic and International Hospital Federation Clinical) Pathology International Hydatidological Association World Confederation for Physical Therapy International League against Epilepsy World Council for the Welfare of the Blind International League against Rheumatism World Federation of Associations of Clinical Toxi- International Leprosy Association cology Centers and Poison Control Centers International Organization for Cooperation in Health World Federation of the Deaf Care (Medicus Mundi Internationalis) World Federation of Hemophilia International Organization for Standardization World Federation for Medical Education International Organization against Trachoma World Federation for Mental Health International Paediatric Association World Federation of Neurology International Pharmaceutical Federation World Federation of Neurosurgical Societies International Planned Parenthood Federation World Federation of Nuclear Medicine and Biology International Radiation Protection Association World Federation of Occupational Therapists International Society of Biometeorology World Federation of Parasitologists International Society of Blood Transfusion World Federation of Proprietary Medicine International Society for Burn Injuries Manufacrurers International Society of Chemotherapy World Federation of Public Health Associations International Society of Endocrinology World Federation of Societies of Anaesthesiologists International Society and Federation of Cardiology World Federation of United Nations Associations International Society of Hematology World Medical Association International Society for Human and Animal Mycology World Psychiatric Association International Society of Orthopaedic Surgery and World Veterans Federation Traumatology World Veterinary Association

INDEX

Index

References are by paragraph. Main references by suiject are zn bold type.

Abortifacient drugs, 6.92 Aircraft, disinsection, 9· I98 Abortion, 6.25, 6.84-6.85, 6.92 Alcohol-related problems, 1.22, 7•15-7.19, 7.2I, ACC, see Administrative Committee on Co-ordination I0.20-I0.24, I2.I08, I5.I05, I5.II6 Accidents, agricultural and industrial, 5. 72 international review, 7.I6 road traffic, 4.27, 5.25, 5.28, 5.29, 5.30, 5.37, I0.2I, Algeria, 8.39, 8.40, 9.22, 9.25, 9.27, 9.8I, 9.I76, I1.25, I5.I05, 15.111 I 5. I20 Acupuncture, 5·52, 5.64 All-Africa Leprosy and Rehabilitation Training Centre, seminar and consultation (China, I 979), 5. 58, 5. 59 9·93 Administration and finance information system, 2.54 Allergic diseases, I o. I 07, I 5. I I 2 Administrative Committee on Co-ordination (ACC), Americas, Region of the, 3·49, 4.I6-4.22, 5.8, 5·I9, 5.26, Sub-Committee on Nutrition, 6.33, 6.39 5·37, 5-38, 5·39, 5.6o, 5.72, 6.47, 7·5, 7·9, 7·I7, task force on rural development, 5. I 3 7.50, 8.7, 8.44, 9.25, 9·94, IO.IO, II.II, II.23, Administrative matters, I4.12-14.23 II.44, I2.I5, I2.22, I2.32, 12.35, 12.78, I2.86, Adolescence, see Youth and adolescence I2,98, I2.I08, I2.II3, 15.24-15.57 Advisory Committee on Health Development, African, Americas, Ten-Year Health Plan, 2.I6, 5.8 I 5.8 Amoebiasis, 4·I7 Eastern Mediterranean, I 5. I 39 Anaemias, nutritional, 6.4I, 6.43 Advisory Committee on Medical Research, Global Andean Group, Fifth Meeting of Health Ministers (ACMR), I.II, 4.4, 4.6-4.7, 6.34, I3·31 (I979), 5.6o Subcommittee on health services research, 5.4I, 5·49 Angola, 3·45, 3.48 Advisory committees on medical research, regional, Animal health, 9.II4, 9.I3o, 9·I32 I.II, I.I7, 4.I, 5.42, 6.43 special programme, Americas, I5.29, I5.52-I5.53 Africa, 4· I 4, 4· I 5, 5·44 see also Veterinary public health Americas, 5·4 5 Anopheline mosquitos, 9·173, 9.176 Eastern Mediterranean, 4.31, 5.48, 5.62, I5.I44 Antibiotics, 8.32, 9.109 Europe, 4.27, 5 ·47 Anticonvulsant drugs, 7·44 South-East Asia, 4.23, 5.46, I5.8o Antidepressant drugs, 7.34, 7·35 Western Pacific, 4.36, 4·37 Apartheid, 3.4, I5.2 Aedes aegypti, 9· I 2 5, 9· I 78 Approaches to planning and design of health care facilities in Afghanistan, 3.52, 7.8, 7.20, 9.25, 9.28, 9·7I, 9·75 developing areas, 5. 31 Aflatoxin, Io.9, I0.27 Appropriate technology for health, 4· I2, 5·14-5.22; African Development Bank, 3·I4 I5.64 Mrican Region, 3.48, 4.I3-4.I5, 5·7, 5.I6, 5.25, 5·34, directories, 5. I 5, I 5.64 5·59, 5·69, 5·7I, 6.54, 7·49, 8.6, 9·24, 9·44, 9·5I, information systems, 2.49, 5. I 5 9.62-9.67, 9·93, I0.9, II.5, II.23, II.26, II.44, I2.2I, Argentina, 4.I9, 8.30, 8.45, 8.46, 9.69, 9·75, I5.38 I2.31, I2.46, I2.49, 12.59, I2.64, I2.77, I2.86, Arrhythmias, 10.59 15.1-15.23 Arthritis, rheumatoid, 5.6I, Io.65 AFRO Newsletter, I5.IO Asbestos, I o. I 9 Air pollution, Io.66, I5.43, I5.89, I5.II2, I5.I28 Asian Development Bank, 3.12, 3·I4 monitoring and control, 5.78, II.7, II.38, II.4I, Associate Members of WHO, (Annex I) II.42, I2.I20, I5.I77 Association of Medical Education in Europe, I 5. I 3 2

247 THE WORK OF WHO, 1978-1979

Association of Schools of Public Health (European Burma, 3.50, 5.68, 5·73, 7.6, 7.20, 7.23, 7·5I, 9.26, Region), I 5. I 32 9·75, 9·I28, 9·I84, I2,30, I5.85 Association of South-East Asian Nations, 8.I2, I3·51 Burundi, 3.48 Atherosclerosis, I0.54 Audiovisual materials, 6.54, I2.85 Cameroon, see United Republic of Cameroon see also Films ; Teaching/learning materials Canada, 3.II, 7.5, 7.2I, 9.2I2 Australia, 3.II, 8.30, 9.29, 9·52, 9.85, Io.37, Io.51, Canadian International Development Agency (CIDA), I5 .I79 I 5•85 Auxiliary health personnel, I2.82-I2.83, I2.86, Cancer, 1.23, 5·55, 6.76, 6.79, 9.I64-9.I65, IO.I-10.39, 15·46-I5·47 I0.83, I5.I73 teacher training, I2.82 control and prevention, national programmes and see also Medical assistants and auxiliaries : Primary common strategy, Io.2-Io.3, IO.II-IO.I5 health care workers ; Village health workers ; coordinating committee, I.7, IO.I-I0.2 and under the various categories of health personnel epidemiology, IO.I3, ro.I6, I0.37, ro.38 Ayurvedic medicine, 5.6I directories, I o. I 7 registries, I0.9, IO.IO, IO.I3, IO.I5, I5.I73 standardization of reporting, Io.6-Io.7, IO.II Bacterial diseases, 9•74-9·1o6, I5.II8 research, I0.9, Io.Io, IO.I2, IO.I5, 1o.16-1o.39 Bangladesh, 3.50, 5·73, 7.6, 7.51, 8.45, 9.22, 9.26, 9·75, training, I0.37-I0.39 I0.63, I 5. 77 screening and early detection, IO.I2, IO.I3, IO.I5 "Barefoot doctors", I2.45 statistics, I3.28 BCG vaccination and vaccine, 8.33, 9.78, I5.79, I5.I7I study group, IARC/WHO, IO.I2 Behavioural studies, 7·37 training, IO.IO, IO.I2 Belgium, 3·39, 7·49, I0.23, Io.37, IO.Io5, I5.I23 Cape Verde, 9·73 Benin, 9.I8, 9·54 Carcinogens, environmental, Io.36 Biologicals, 8.29-8•37, 9.6 see also Chemicals, carcinogenic production and quality control, 8.2, 8.29, I5.38 Cardiology, congresses, I0.44 standardization, 8.36, 8.48 Cardiomyopathies, classification, I o. 59 international reference materials, 8. 32 Cardiovascular diseases, 5·55, 10.40-I0.59, I5.I7, Biomedical information, I3.I, 13·30·13·55 I5.I05, I5.I22-I5.I23 Biomedical research, see Research classification, I0.59 Birth control, see Fertility regulation community control, I0.42, I0.47, I0.49, I0.50, Birthweight, low, 6.I7 I2.II7, I5,I22, I5,I73 Blindness, prevention, 3.27, 6.4I, 9·51, 9·145-9·150 drug evaluation trials, Io.p national programmes, preparation, 9.I46, 9·I48 long-term programme of WHO, ro.4o advisory group, 9· 146 primary prevention, plan of action, I0.4I training, 9.I46, 9.I47, I2.II2 registers, I o. 5I Blood products, 8.p, 8.34, 8.39 research, 4.27, Io.48, I0.51-I0.54, I0.58, I0.64, Blood transfusion: A guide for the formation and operation I 5. I22 of a transfusion service, 8.4 7 studies on physical activity, ro.57 Blood transfusion services, 8.39, 8.40, 8.45, 8.46 training, I 2. I I 7 Boletin de Ia Oftcina Sanitaria Panamericana, I3·43 Caribbean area, 9.26, 9.76, 9·94, 9.126, I2.I5, I2.46, Bolivia, 4·I9, 9.25, 9.68, 9.76, I5.38 I5·38, I5·47 Botswana, 3·45, 3.48, 5.24, 7·49 Caribbean Community, 8.I2 Bovine tuberculosis, 9· I 52 Caribbean Epidemiology Centre, 9·94 Bowel cancer, I0.25 Caribbean Food and Nutrition Institute, 4.22 "Brain drain", see Migration of health personnel Caribbean Regional Drug Testing Laboratory, 8.I2, Brazil, 4.I9, 4.2I, 7.3, 7·I4, 8.24, 9·31, 9.32, 9.42, 9.48, 8.I9 9.68, 9.69, 9·75, 9.76, 9.I67, 9.2I5, IO.I03, IO.I04, Caries, 6.45. Io.67-Io.7o, I5.I74 I2.I5, I5·47 Casual income, use of, to reduce the adverse effects of Breastfeeding, 6.5-6.6, 6.19-6.2o, 6.34 currency fluctuations in WHO, r.8 Bronchial carcinoma, I0.29 Cerebral palsy, 5.29 Brucellosis, 9.I52, I2.II3, I5.83 Cerebrospinal meningitis, 3.48, 9·ID3·9.I04 Brunei, 9.29 Cerebrovascular diseases, 7·43 Bulgaria, 7.rr, 9·I53, ro.58, I0.94 international symposium on cerebrovascular accidents Bulletin of the World Health Organization, I3·37 (I978), 7·45 Burkitt's lymphoma, I0.9, Io.28 Chad, 3.48 INDEX

Chagas' disease, 9.68-9.70 human genetics, IO.I02 research, 9. 2 27 human reproduction, 6.69-6.75 Chagas' Disease Vector Research Unit, Venezuela, 9.68 research and training, 6.69, 6.73 Charter for Health Development, I 5. 59 immunology, IO.I03 Chemicals, in food and the environment, 1.23, 5.72, laboratory animals, 9.I66 Il.9•II.II, I1.34, I1.39, I5.126-I5.I27 manpower development, I2.I7 mental health, 7.54, I5.I65 carcinogenic, Io.I6, I0.24, 10.32-Io.36, II.IO neurosciences, 7.42 Children, I 5.I I2-I 5.I I 3 nuclear medicine, Io.88 cancer, I5.II2 occupational health, 5. 78 cardiovascular diseases, I0.54 communicable diseases, 9.2, 9.78, 9.I04, 9.I24 pesticides, 9· I74, 9· I75 radiation, II.39 diarrhoeal diseases and gastroenteritis, 9·I40, I5.8I rickettsial diseases, 9· I 3 I growth and development, 6.2I-6.22, 6.28, 6.29-6.3 I, smallpox, 9.I4, 9.20 6.38, I5.II3 streptococcal infections, 9· 10I, 9· 102 effects of air pollution, I 5. II 2 teacher training, I 2. 79 psychosocial development, 6.22 traditional medicine, 5.64 mental health, 3.I6, 7.3, 7·9 veterinary public health, 9· I 69 mortality, 1.20, 6.I7, I3.27 nutrition, 6.5-6.6, 6.32, 6.34, 6.35, 6.45, I5.II2 Colombia, 7.4, 7.5, 7.38, 7.50, 9.22, 9.25, 9.76, 9.8I, oral health, Io.68, I0.69 9.I67, I0.25, I0.8o, II.44, I2.22, I2.26 see also Immunization ; International Year of the Commission of European Communities, 3·I5, 3.48, Child ; Maternal and child health 10.53 Chile, 4.I9, 7.5, 9.8I Common oral diseases, prevention and emergency care: China, 3·I9, 3·29-3·30, 5·34, 5.58, 5·59, 6.27, 6.93, A manual for teachers, I2. I 3 3 9·29, 9·31· 9·49. 9.II3, 9.I26, 9·I70, 10.I5, I2.45, Communicable diseases, 9·1-9.239, I5.I5-I5.I6, I2.62, I2.95. I4.6, I4·7 I5·36-I5·39. I5·74-I5.85, I5.I67-I5·172 Chlamydia! diseases, 9.I23 control programmes, 9.2, 9·4, 9·35, 9.40, 9.42, 9·54, Cholera, 3·45, 3.48, 9.106, I5.I5 9.68, 9· I 29, 9· I40 Chromosomal diseases, 10.IOI epidemiological surveillance, 9·3-9·5, 9·I34, 9·I4I, CIDA, see Canadian International Development Agency 9·I5I, 9·I56-9.I59. I5.I5, I5·74, I5.82 CIOMS, see Council for International Organizations of immunology, IO.I05, IO.Io8 Medical Sciences integration of services in primary health care, 9.2, Cirrhosis, I0.2o, I0.2I 9·44. 9·75, 9.82, 9·83, 9·84, 9·93. IHO-I5·37· CMEA, see Council for Mutual Economic Assistance I5.80 Coastal water pollution, 3.42, I 1.43, I4. Io see also Expanded Programme on Immunization ; Codex Alimentarius Commission, 9.I58, II.46-II.48 Tropical diseases "Cold chain" development and management, 9.205, Communicable eye diseases, see Blindness ; Trachoma 9·208, I2.I36, I5·38, I5.84 Community health workers, training, 5.9, 5.26, 6.37, Collaborating centres, I. II, 4.36, I0.65, I2.I23 7•3I, 12.46, 12.50, I2.p, I2.96, I2.98, I5·93 blindness prevention, 9.I47, I2.II2 interregional study, 5·I3, I2.44 cancer, I0.5, IO.I5 Community participation in health and development cardiovascular diseases, I0.57 programmes, 2.9, 5·7, 5.8, 5·34, 5·35, 6.46, 7·3· chemical reference substances, 8.24 7·39, 9·205, II.5, I5·34. I5·70 comparative medicine, 9.I65, 9.I68 joint study, UNICEF/WHO, 6.46 dengue haemorrhagic fever, 9.I27, Io.106 training programme, Central America and Panama, dental caries and periodontal disease, I 5. I 74 5·8 diarrhoeal diseases, I.2o, 9·I43 Comparative medicine, 9.I64-9.I7I, I0.33 drug dependence and alcohol-related problems, Computing, medical, I3.I5, I3.I6, I3.I8 7·2I, 7·23 see also Electronic data processing drug monitoring, international, 8.27 Conference on the Child and the Adolescent in Society educational technology, 7·4 (I978), I5-JI3 environmental health, II.28, II.3I, II.34, II.38, IL39 Conference of Experts for the Defence of Society family planning, 6.98 against Natural Disasters in the Mediterranean food contamination monitoring, I 1.50 Basin (I979), 3.42 food virology, 9·I59 Congenital anomalies, 6. 76 health services development, 5·49, I2.I7 Congo, 3.48, 9·44, 9.63, 9.I86 health services research, 5.42, 5·44, 6.98 Congo virus, 9·I33

249 THE WORK OF WHO, 1978--1979

Connective tissue diseases, Ioo65 research, 90 I27, IOo Io6, I 5 082 Consanguinity and disability, study, 5 o29 vector biology and control, 9oi78, I5o85 Constitutional and legal matters, J4ol-l4oii Denmark, 3oii, 5074, 7oi4, 7049, 9oiOI, 9oi99, IOo2I, amendments to the WHO Constitution, I4o2-I4o5 IOo25, I0o58 Contraceptives, injectable, 6025, 6076, 6o8I-6o82, 6087, Dental health, see Oral health 6o90, 6093 Depression, treatment, 7034, 7°35, 7o37 oral, for men, 6087, 6093 international symposium (Washington, I979), 7o35 for women, 6025, 6078-6079, 6086 Development fomm (United Nations), I3o62 postcoital preparations, 6087, 6093 Development projects, see Rural development ; Socio­ see also Abortifacient drugs ; Fertility regulation ; economic development and health ; United Nations Intrauterine devices Development Programme; Water resources and Contributions to WHO, voluntary, see Extrabudgetary river basin development projects sources of funds Convention on Long-Range Transboundary Air Development strategy, new international, 1.3, Ioi4, Pollution, I5oiZ8 3o2-3o3, 3o5, I5o63 Convention on Narcotic Drugs, 7026 Diabetes, 4037, 5055,6045, Ioo62-Ioo64, I5o86 Convention on the Privileges and Immunities of the study of vascular diseases in diabetics, IOo64 Specialized Agencies, I4o6 training courses, I2 o 97 Convention on Psychotropic Substances, 7026 Diagnostic substances, 5 o47, 8ol-8o48 Coordination with the United Nations system of see also Reagents organizations, Io2-r.3, 3ol-3o5, 3044, 4oi0-4oi2, Diarrhoeal diseases, r.2o, 3oi9, 5oi2, 6oii, 6036, 8040, 5o8I, 6o28, 7o48, IOo4I, II.I2-II.I3, II.I9-II.20, 9o43, 9ol40-9ol44, I5o39, I5o8I, I5oi69 I3o62, I5o7I, I5oi40 national programmes, preparation, 9oi40-9oi42

restructuring of economic and social sectors, 3 0 22 technical advisory group, 90 I40 see also under names of indit•idual organizations research~ 406, 4o7, 4oi5, 4o17, 4°25,4037, 9°122, 9oi43, Cor pulmonale, I5o86 I5oi45 Coronary heart disease, IOo20 international centre, Dacca, 9oi44 Costa Rica, 4o2I, 705,7050, IOoiO, IZo30 training, 9oi4I Council of Arab Ministers of Health, I2o37 Dietary causes of disease, IOo22, IOo23, IOo25 Council for International Organizations of Medical see also Food and foodstuffs Sciences (CIOMS), 2oi2, 5038, I3o53 Diphtheria, 9o99 Council for Mutual Economic Assistance (CMEA), 3 0 I 5 vaccination and vaccine, 8033, 9o99 Country health programming, 1.9, 2o3-2olo, 20 I I, I2o20, see also DPT vaccine I5o6o, I5o9I, I5o106, I5oi53, I5oi79 Director-General's Development Programme, 4024 interregional seminars, 2oiO Directory of persons and institutions related to WHO training, 2.21, 12.21, 12.29 programmes, 2052 Cretinism, 6o4I Disability prevention and rehabilitation, 304, 5o23-5o3o, Cryobiology, 9oi66 5-37, 7o37 Cuba, 4o2I, IOoi04, I4o7 training 5o24, 5o25, 5026, 5o27, 5o29, IZo98 Culecine mosquitos, 9oi77 Disarmament, Io29 Currency fluctuations, r.8 Disaster relief, see Emergency assistance Cyprus, 3o52, 9o25, 9o28, I4o23 Djibouti, 9oi2, I4oi Cysticercosis, 9o I 5 I Documents (WHO), I3o36, I4o20 see also Hydatidosis information system, I3o32 Czechoslovakia, 90102 Dominican Republic, 3049, 4o2I DPT vaccine, 9099, 90209 Drinking-water, 1.5, IIo23, IIo3o, I5o87, I5oi76 Danish International Development Agency (DANIDA), standards, II.34, I5oi29 2oiO, 5059, 5o73, 9078, 9oi8o, 90212, 10o9I, II.5, supply, international decade (I98I-I99o), 1.5, 3oi9, II.34, I3o58 I I.2, Iloi4-II.21, I 1.24, I !.2 5, I 1.26, I 1.30, Data banks, Ioo67, Ioo69, I3o30 I4oi4, I5-40, I5·176 DeclarationofAlma-Ata, VII-X, I.2-r.3, 5oi, IZo4, I5o9 Drug information, 8026 Declaration of the Rights of the Child, 6o30 Drugs, availability and use, 4031, I5.II7, I5.I45 Democratic Kampuchea, 9o29 dependence and abuse, 304, 706, 7oi8, 7·20-7.31, 7o5 I, Democratic Yemen, 3o27, 7o8, 9o25, 9°28, 9o75 I2oi03, I5.I05, I5oii6 Dengue and dengue haemorrhagic fever, 8o40, epidemiology and surveillance, 7o23, 7o24, 7025 9oi26-9oi27, I5o38, I5o82, I5o85, I5oi69 information systems, 7.23 INDEX

Drugs, dependence and abuse (continued) mental disorders, prevention, 7 0I 2 training in laboratory techniques, 7024 nutrition, 6.30, I5oiOO training in surveillance, I2oi03, I2o108 proposed world assembly (I982), I.2I essential drugs, I.I2, I.I3, 4oii, 5o2o, 802, 804, 808, Electronic data-processing, 2o5 5-2o6o 8ol2, 8o13-8.15, I5.I9 Emergency assistance, 3o24, 3.36-3.56, I 1.37, I4.23, establishment of WHO special programme, IH9 Io24-I.26, 8.I3, I5.I9 interregional seminar (I978), 3038, 5·37 formulary committee, Eastern Mediterranean see also Health care, emergencies Region, 1.26 Encephalitis, Japanese, 8040, 9.I28-9oi29, 90179, I5o85 minimum list for treatment of neuropsychiatric vaccination and vaccine, 9o I 29 disorders, 7o3 5 Entomologists, training, I 2o II 5 monitoring system for adverse reactions, 8.27 Environmental health, 9oi4I, u.I-u.5o, I5oi4, national policies and management, I.I2, I.26, I5·40-I5o44, I5o87-I5.89, I5.126-I5oi29, I5.I49, 8.1-8.12, I5oi9, I5.I66 expert committee, Africa, 8.6 I5.I75-I5·177 Center for Human Ecology and Health, Pan nonproprietary names, 8025 American, 4022, II. II, IIo4I, I5o4I quality control, 30 I9, 806, 8.18-8.22 centre for promotion of environmental planning certification scheme 8 020 and applied studies, Western Pacific Region, good practices, 8 02 I reference substances, 8023 IIo8, I5·175 criteria, WHO programme, II.3I, II.32, I1.33, I1.43, regional information centre, South-East Asia, 1.26 research and development, 5o47, 809, I5oi45 I5o43, I5o89 monitoring and surveillance, II.35, II.38, I2oi20 safety and efficacy, evaluation and monitoring, 6076, national planning and establishment of agencies, 7o35> 7o36, 8o26 II.3-II.8, II.30, I5oi4, I5o42 see also Abortifacient drugs; Anticonvulsant drugs; research, 4oii, 4022, 4.27, II.9, II.29, II.35 Antidepressant drugs ; Contraceptives, oral ; training, II.6, II.7, II.8, II.II, Il.23, II.25, Ilo26, Filaricides ; Pharmaceutical production ; Phar­ macology, clinical II.38, I2.25, 12·93> I2oi20-I2o122, I4oi4, I5.I4, I5o4I, I5o89, I5oi27, I5.I46, I5oi75 Dusts, industrial and vegetable, 5o8o, 10.I9 see also Chemicals in food and the environment ; Environmental pollution and hazards ; Sanitary and public health engineering ; Sanitation ; Eastern Mediterranean Region, 3·52, 4031-4.35, 5oii, Sewerage; Wastes disposal; Water supplies 5oi9, 5o29, 5o32, 5·37> 5o62, 5o75, 6.9, 7o8, 7o53, Environmental health criteria, I I. 31, I 3.40 8.10, 8o38, 8.44, 9·28, 9o43, 9o7I, 9o200, IOoi3-10oi4, Environmental monitoring system, global, I 5089, II.7, II.23, II.44, I2oi8, I2o25, I2.37, 12o8o, I2o86, I 5o I77 15.135-15.152 Environmental pollution and hazards, 1.23, 5.72, 5078, Ebola virus, 9· I 3 3 II.6, II.3I-II.43 ECA, see Economic Commission for Africa see also Air pollution ; Chemicals ; Coastal pollution ; ECE, see Economic Commission for Europe Soil pollution; Water pollution Echinococcosis, 90 I 5 I Epidemiology and epidemiological surveillance, 5. 36, Economic Commission for Africa, 9oi54 9·3-9•5, 9·I4, 9o 22, 9·35, 9·105, 9oi25, 9·I34> Economic Commission for Europe, II.43, I5oi28 9oi4I, 9·I51, 9oi56-9oi59, 9·217, 15oi5, I5o74> Economic order, new international, I.I3, 3·3, I5o4, I5o82, I5oi55, I5oi68 I 5o63 research, 90232, I5o86 Ecuador, 40 I9, 5.6o, 9068, I 1.44 training, 904, I2oll2, I2oii3, I5o74, I5.93, I5oi2o, Education, see Health education ; Medical education I 5o I68 Educational handbook for health personnel, 12o 73 Epilepsy, 7·43 Educational technology, 12o 57, I 5o95 Epstein-Barr virus, 1009, IOo28, IOo29 centres, Geneva, 12o87 Equipment, medical, repair and maintenance, 5oi9, 5o32, Latin America, I2o32, 12o78 8o39, 8o44, I2.128 see also Teaching/learning materials and processes pesticide and insecticide application, 9035, 9o175 Egypt, 4o32, 5o68, 5o75, 7o3, 7.8, 7·I4, 7o2o, 9o3o, 9o42, see also Supplies and equipment 9oi30, 9oi53, 9oi9I, 9oi96, I2oi35 Essential drugs, see Drugs, essential El Salvador, 9.25 Ethiopia, 9oi2, 9o93 Elderly, care of, I.2I, 304, 4o27, 5.28, 5o29, 5o30, I5.I05, EUR 0 reports and studies, I 5. I 3 3 I 5. I IO European Economic Community, I2o24, I4.23 THE WORK OF WHO, 1978-1979

European Medical Research Council, 4.29 Fadlitating teafhtngflearning with modules: An approafh European Region, 3·5I, 4,27-4·3o, 5.Io, 5.I8, 5.28, 5·37, for nurse mid2vije teafhers, 12.48 5•74, 6.10, 6.24, 7•7, 7.I8, 7•52, 9.27, 9·I56, I0,12, Family health, 6.1-6.103, 7·37• I3.17, I5,II-I5.I3, II.6, II.II, II,23, II.44, I2,I6-I2,I7, I2.24, I2.33, I5.65-I5.70, I5.II2-I5,li4, I5.I6I-I5.I64 12.36, I2.p, I2.79, I2.86, 12.93, lj.I04-15•134 integration with general and primary health care publications, I5.I33-I5.I34 services, 6.I-6.3, 6.29, 6.57, I5.II, I5.I2 European standards for drinking-water, I I. 34 medium-term programme of WHO, 6.2 European Thrombosis Research Organization, 10.5 3 research, 4.II, 6.49 Evaluation of programmes, 2,40-2.45, I5.I09 training, I 5.66 development of guidelines, 2,I3, I5.I09 see also Maternal and child health national, 2, I 3-2. I 8 Family planning, 6.25-6.26, 6.57-6.58, I5.65, I5.I14, interregional meeting (I979), 2.I8 I5.I63 regional, 2.32, 2.4I-2.45, 2.47, I5.I09, I5.I5o research, 4.II, 6.7, 6.25, 6.26 Excreta disposal, I5.87, I5.176 on psychosocial aspects, 6.94-6.95, 7.38 staff, medical and nonmedical, 6.97, 6.98 Executive Board, I. I, 1.24, I.27, 1.28 role of nurses and midwives, 6.97 Ad Hoc Committee on Drug Policies, 1.25, 8.I3 training, 6.25, 6.27, 12.95, I2.I30 ad hof committee on malaria, appointment, I. IS see also Fertility regulation ; Special Programme for Ad Hoc Committee on WHO's Activities in the Field Research, Development and Research Training ofCancer, IO.I in Human Reproduction membership, 14.2-I4.3, 14.8 organizational studies, 1.9-I.II, I2,29 FAO, see Food and Agriculture Organization of the Programme Committee, 1.6-1.8, 2.p, 4.2-4.4 United Nations Expanded Programme on Immunization, 2.49, 3.27, Fellowships, 3.38, 4.3, 9.235, u.6s-u.67, 15.I84 6.II, 9·99, 9•202-9.212, I0.87, I5.I5, I5.37, I5.84, programme regionalization, 12.67, I 5·97 I5·142, I5.I7I Fertility, I3.27 global advisory group, 9.204 Fertility regulation, 2.49, 6.17, 6.20, I5.I63 reporting systems, 9,206-9.207 research, 6.59-6.6o, 6.76-6.93, 7.38, I5.I63 Expert Advisory Panel on the International Phar­ natural methods, 6.83, 6.87, 6.9I macopoeia and Pharmaceutical Preparations, 8.23 new methods, 6.86-6.93, IO.II2 Fibres, man-made, health hazards, IO.I9 Expert Advisory Panel on Traditional Medicine, Fiji, 5.76, 8.22, 8.40, 9.85, 9·97, IO.I5, 12.46 establishment, 5.65 Filarial infections, 8.40, 9·48-9.6I, 9· 177, I 5.85 Expert advisory panels and committees, organizational chemotherapy and chemoprophylaxis, 9.48, 9·49· study, I.II 9·50, 9·53 Expert Committee on Arterial Hypertension (I978), research, 9.5o, 9·53, 9.22I-9.223 10·45 vector biology and control, 9.II7, I5.85 Expert Committee on Cancer Statistics, WHOfiARC see also Onchocerciasis (I978), IpS Filaricides, 9· p, 9.222 Expert Committee on Controlling the Smoking Finland, 7.27, 9.212, I0.25, Io.8I, I5.I23 Epidemic (I978), 10.5 5 Fluorides in dental health, Io.7o, 10.75 Expert Committee on Diabetes (I979), Io.62 Food additives, I 1.49, I 5. II 2 Expert Committee on Environmental Management see also Food safety and hygiene for Vector Control (I979), 9·I97 Food and Agriculture Organization of the United Expert Committee on Food Additives, Joint FAO/ Nations (FAO), 6.48 WHO (I978 and I979), I 1.49 joint activities, communicable diseases, 9.66, 9.67, Expert Committee on the Selection of Essential Drugs 9· I96, I0.9 comparative medicine, 9.I68, 9.I69 (I977), 1.24, 8.I3 food safety and hygiene, 9.I56, 9·I57, 9.I58, I0.27, (I979), 8.I4 I I. 37, I 1.43, II.46-II.j0 Expert Committee on Specifications for Pharmaceutical nutrition, 6.39, 6.45 Preparations (I979), 8.I9 veterinary education, 9.I6I Expert Committee on Vector Biology and Control zoonoses, 9· I 5 I (I978), 9.I87 Food contamination and hazards, 1.23, 10.9, I0.27, Extrabudgetary sources of funds, 3·9-3·I5, 3·45, 6.Io3, II.49-I1.50, I5,II8 7·I4, 8.34, 9.36, II.I9-Il.2I, II.24, 12.9, 14.23, joint FAOfUNEPfWHO monitoring programme, I5·54-I5·57· I5.88, I5.I04 II. 50 WHO Secretariat committee, 3.Io, I 1.20 see also Chemicals INDEX

Food and foodstuffs, fortified, 6.42, 6.43 Health, attainment by the year 2000 of a level permitting weaning foods, 6.6, 6.35 a socially and economically productive life, Food safety and hygiene, II.44-II·50, r 5.90, 3,1-3.2, 4.II, 5.1, 12,5, 15,8, 15.24-15,26, 15.5S, I5,130-I5,131 15.62, 15.103, 15.104, 15.135 microbiological aspects, 9· r 57, 9· r62, r 1.45, r 1.4S, "Health 2ooo" resources group, 3.ro I2.II4 research planning, 4·4 training, 11.44, 11.45, I2.II4 strategies, r.2-r.5, 3·33, 5·9, 6.29 Food standards and criteria, r 1.46-r r.4S Health care, delivery, 5.ro, 5.18, 5·31• 5.32, 5·33, 5.46, Foodborne diseases, 9.155, 9·I56-g.rs9, 9.r6r-9.r63, 15.22 I 1.44, I 5. I 30-15, I 31 emergencies, services in, 5. 37, 7. 7 training, I2.II4 obstetrical, r 2. S8 Foot-and-mouth disease, 9· r p, r 5. 53 research, 4· 34, 5·4 7 France, S.3o, ro.2o, 10.22, 10.24, 10.25, 10.35 see also Primary health care French Polynesia, 9.126 Health economics, 5.38, 5·47 Health education, 5.ro, 5.21, 5.69, 6.46-6.56, 9.40, I 3•57> 15. II, I 5. 70, I 5. II 3 Gabon, 9.63 in communicable disease control, 9.40, 9.68 Gases and vapours, health hazards, 5.7S in diabetes, ro.63 General Programme of Work of WHO, Sixth, 2.29, in environmental health, 6.p 2, 34, 9.2, I 2.S in family health, 6.47, 6.4S, 6.49 review, r.6 in nutrition, 6.20 Seventh, preparation, r.6, r. 14, 7. 55 in occupational health, 5.69 Genetic disorders, 1.23, I0.93-ro.roo on tobacco, alcohol and drug abuse, 6.51, 7.rS, ro.55 Genetic engineering, 9.S training of staff, 6.50, 6.54, 12.96, I2.IOI, Ij.II, 15.70 Genetic markers, ro.94-I0.9S Health and the family, 13.27 Genetics, human, ro.93-ro.ro2 Health laboratory services, see Laboratory technology Geriatrics, see Elderly, care of and services German Democratic Republic, 6.93, 9.31, 15.10 Health legislation, r 3.4S- r 3. 5 r Germany, Federal Republic of, 3.rr, S.r9, S.2S, 9·44, mental health, 7·13-7·14 9•52, 9.S3, 9.199, IO,q, I0.5S, IO.S2, 11.24, 15.SS Health literature services, I3.30-I3.33 Ghana, 3.4S, 5.71, 7.rr, 9.40, 9·51, 9·54 Gilbert Islands, see Kiribati information system, 2.50, I3.30-I3.31 Giovanni Lorenzini Foundation, 9.S see also Guides ; Manuals ; Teaching/learning materials ; Goitre, endemic, 6.41, 6.44 Textbooks Gonorrhoea, r 5. r 69 Health management, 1.9, 1.27, 2.ro, 5.31, 15.6-r5.7, Governing bodies, see Executive Board ; Regional I5•50-I5·5I committees; World Health Assembly information systems, 2.24, r 5. 5 r, r 5. r 54 Greece, 5·74, 9.153, rr.6 training, 2.19-2.2r, 2.29, 9.205, r2.28-r2.33 Greenland, ro.Sr centres, Africa, 12,21, 12.31, 12.59, 15.7 Guam, 9·75 Health manpower, see Manpower development, manage­ Guatemala, 9· 2 5, 9· r So, r 1.44 ment and planning Guides, technical, 2.13, 2.14, 3.24, 3·43, 5·77, 5.7S, Health planning and programmes, national, develop­ 6.25, 6.36, 6.50, 6.ror, S.4, S.5, S.39, 8.48, 9·7· 9.91, ment, 2.3-2.27, 2.29 9,127, 9,129, 9.149, !0,2, 10,74, 11.3, 11.33, II.4I, evaluation, 2, r 3-2. r S 11.42, 11.49, 11.50, 12.20, 12.34, 12.42, 12,43, interregional meeting (1979), 2.18 12.54, 12.76, I2.S2, 15.109, 15,121 provisional guidelines, 2, r 3 see also Manuals, technical information systems, 2.22-2.27, 13.3 Guinea, 9.r8o interregional seminars, 2. ro Guinea-Bissau, 9· r So monitoring, 2. r 5, 2. r 7 Guyana, 8.q, 9.4S training in management, 2.19 see also Country health programming ; Environmental Haemoglobinopathies and allied disorders, ro.98, ro. roo health, national planning ; General Programme Haemorrhagic fever, 9· r 32-9. r 3 3 of Work; Programme of WHO vaccine, 15.3S Health records, see Medical records see also Dengue and dengue haemorrhagic fever Health sciences, training centres, meeting of deans and Haiti, 9.22, 9.25, 9.176 directors, 12.59 THE WORK OF WHO, 1978-1979

Health services, development, 5.1-5.81, 6.II, Immunization, I.2o, 6.51, 9.202 I5.22-I5.23, I5·30-I5·35, I5-48, I5.60-I5.64, Expanded Programme, 2.49, 3.27, 6.I I, 9·99, I5.I08-I5.I09, I5.I32, I5.I57-I5.I6o 9-202-9.212, I0.87, I5.I5, I5-37, I5.84, I5.I42, financing, 2.12, 5·38-5.40 I5-17I seminar (Mexico, I979), 5.38 research, 9.208, I 5·3 8 planning and management, 5·31·5.40, I2.I5-I2.I9, training, 9.205, 12.92, 12. I 36 12.45, I 5.22 Immunology, 4·37, 9.2I5-9.2I6, 9.227, 9·23o, regional ministerial consultation, Eastern Medi­ 10.103•10.II2 terranean (I978), 12.I8, I5.I36 centres for research and training, Io.Io3, IO.Io4, see also Health management ; Health programmes, IO.I05, I2.II9 national, development ; Manpower develop­ India, 3·45, 4.23, 5.27, 5.6I, 6.85, 7.3, 7.6, 7.38, 8.30, ment, management and planning ; Public health 8.35, 8.48, 9·22, 9.26, 9·3I, 9·7I, 9,76, 9·78, 9-I28, administration 9-I29, 9.I62, 9·179, 9·23I, I0.95, I5·77> I5·79 Health services research, 1. 7, I. 17, 4.3, 4.6, 4.25, 4.27, Indicators of health status, 2.I8, 6.4, 7.II, I3.25, I5.I09, 4.32, 4·37, 5·41·5·49, 6.4, 6.I5, 6.25, 6.26, 6.6o, I5.I54 6.96-6.98, 7·32, l2.I3, I5.2I, I5·46, I5-92, I5·98, Indonesia, 3.5o, 5.27, 5.68, 7.6, 7.20, 8.48, 9.26, 9·49, I5.I07, I5.I44, I5.I56, I5.I57 9.176, 9·177, 9.178, 9.I85, IO.II standardization, 5·4 7 Industrialization, I5.43, I5.89, I5.I05, I5.II2 task force, Western Pacific, 5·49 training, 5·44, 12.99 Infant mortality, I3.27, I5.II2 Health statistics, see Statistics Infertility, 6.99, 9· Io8 Health teams, 6.27, I2.2, 12.44, I2.82, I5.9I-I5.92 research, 6.6o, 6. 76, 6.99 Helminthic and protozoal infections, intestinal, 9· 73 Influenza, 9.84, 9.II3-9.II4, 9·I70 Hepatitis, viral, 9.II6-9.II9, I0.26-Io.27, I5.II8 vaccines, 9· I I 3 vaccination and vaccine, 8.36, 9.II6 Information of the public, see Public information see also Liver cancer and other chronic liver diseases Information systems, 2.22-2.27, 2.54, 3.4, 5.Io, 12.26, Histological classification of tumours, 9· I 65, 10.4 I2.I25, I3.II-I3.I4, I3.30-I3.3I, I3.32, I5.49, Honduras, 9.25 I5.67, I5.154 Hong Kong, 9.29, 9.78, 9·I7o, 10.58 WHO programme, 2.46-2.61, I3.I Hospitals, planning, administration and maintenance, questionnaires, 2. 5 3 5·31, 5·32 Insecticides, application, evaluation and testing, 9· 3 5, information systems, I3.IO 9·56·9·57, 9·65, 9·I73, 9·174, 9·176, 9·178, patient management (flow charts), I2.88 9·I8I-9.I82, 9·I95, 9·I98, 9·I99, 9·226, I2.II5, I5·77 see also Medical records equipment, 9·35 Human ecology, I r.6 training, I 2. II 5 Pan American centre, 4.22, II.II, II.4I, I5.4I ultra-low-volume applications, 9· I 82 Human genetics, 10.93-IO.Io2 resistance of vectors, 9.25, 9·3 5, 9· 173, I 5.172 Human reproduction, I 5. II 2 see also Pesticides research, development and research training, special Institute of Nutrition of Central America and Panama programme, 2.49, 4.26, 6.57-6.103, 7.38, IO.II2 (INCAP), 4.22 see also Family planning ; Fertility ; Infertility ; Insurance, health, 2.9 Sterilization Inter-American Indian Institute, 5.Go Human rights, 3·4 Inter-Governmental Maritime Consultative Organ- Human settlements, I I. 8 ization (IMCO), I 1.43 Hungary, I 3.27 Intergovernmental organizations, (Annex 3) Hydatidosis, 9· I 51, 9· I 52 International Agency for the Prevention of Blindness, Hypertension, arterial, 4.30, 5.47, 6.45, 10.45-10.49, 9·148 I 5.I07 International Agency for Research on Cancer (IARC), WHO community control project, 10.47 IO.I, I0.2, I0.3, I0.7, I0.9, 1o.I2, IO.I5, 10.16- 10.39, II.Io, I3.28 publications, 10.3 2 IAEA, see International Atomic Energy Agency International Air Transport Association, 9.8 IARC, see International Agency for Research on Cancer International Association of Cancer Registries, I o. 7 Illiteracy, I2.89 International Atomic Energy Agency (IAEA), 10.58, ILO, see International Labour Organisation I0.84, I0.85, I0.87, II.37 IMCO, see Inter-Governmental Maritime Consultative International Children's Centre, 6.12, 9.207, I 5. I I4 Organization International Civil Defence Organization, 3.38 INDEX

International Classification of Diseases, 10.4, I3.2o- International Society and Federation of Cardiology, I3.24 10.49, 10.5 3, 10.59, I2.II7 centres, I 3.24 International Society of Hypertension, 10.47 Ninth Revision, I2.I24, I3.2I, I3.22 International Society of Radiographers and Radiological Tenth Revision, I3.24 Technicians, I2.II8 International Classification of Impairments, Disabilities International standards for drinking-water, revision, I1.34, and Handicaps, I3.2I I5 .I 29 International Classification of Procedures in Medicine, International Union of Architects, 3.38 I3.2I International Union against Cancer, I0.2 International Commission on Radiological Protection, XII Congress, 10.3 II.37 International Union of Health Education, 6.I2 International Union oflmmunological Societies, IO.I09 International Computer Centre, 2. 55 International Conference on Economics and Health International Union of Nutritional Sciences, 6.12, 9·I48 International Union against Tuberculosis, 9.76, 9.77, Policy (I979), 5-38 9.86, 9·93 International Conference on Primary Health Care (I 978), International Vitamin A Consultative Group, 6.42 1.2, 3•I7, 5.I, 8.2, I2.4, I5•9 International Year of the Child (I979), I.I9, I.20, 3.4, International Conference on Traditional Asian Medicine 3·48, 6.I3, 6.28, 6.29-6·31, I5.I3, I5.I42-I5.I43 (I979), 5·57 International Year for Disabled Persons (I98I), 5.24 International Council for Adult Education, 5. I 3 Intrauterine devices, 6.25, 6.8o, 6.86, 6.87, 6.89 International Council of Nurses, 12.47, 12.74 Iran, 9·25, 9.28, 9·30, 9·7I, 9·I73, I5.I36 International Dairy Federation, 3.25 Iraq, 5·75, 7.8, 8.45, 9·25, 9.28, 9·3o, 9·7I, 9·I32, 9·I33, International Dental Federation, 10.7I, I0.72, 12.I33 9·I99, 9.200, II.7, 12.II5 World Congress (I979), 10.7I Irrigation, see Water resources and river basin develop- International Development Research Centre, I 3· 3 I ment International Diabetes Federation, I0.63 Ischaemic heart disease, Io.p-I0.53, I0.59, I5.I23 Islamic Development Bank, 3.I2, 3-I4 International Digest of Health Legislation, I3·50-I3·5I Israel, 9.25, 9.28, IO.I04 International Drinking-Water Supply and Sanitation Italy, 9.8, I0.22, IO.Ioo Decade (I98o-I99o), 1.5, 3·I9, II.2, 11.14-II.:n, Ivory Coast, 5.7I, 9·54, 9.64, 9·174, 9.I8I, 9.I82, 9.I99, II.24, II.25, II.26, II.30, I4.I4, I5-40, I5.I76 I2.II5 International economic order, new, I.I3, 3·3, I5.4, I5.63 International Epidemiological Association, I I. 3 5, I2.I3I, I3·7· I5.I09 International Federation of Anti-Leprosy Associations, Jamaica, 8.46, IO.I04 9·9° Japan, 9.29, 9.p, 9.8I, Io.86 International Federation of Gynecology and Obstetrics, Japan Shipbuilding Industry Foundation (Sasakawa 6.12, 6.29 Memorial Health Foundation), 3.II, 9.96, 9·I5o, International Federation of Health Records Organ­ 9-2I2 izations, I2.I32 Joint Committee on Health Policy, UNICEF/WHO, International Federation of Ophthalmological Societies, 3-16-3.17, 5·I3, 6.27, 9-I42, II.22, 12-94 9·I48 Joint FAO/UNEP/WHO food and animal feed con­ International Federation of Sports Medicine, Io.n tamination monitoring programme, I I. 5o International Health Regulations, 9·5 Joint F AO/WHO Expert Committee on Food Additives International Histological Classification of Tumours, (I978 and I979), II.49 9·I65, 10.4 Joint FAO/WHO meetings on pesticide residues (I978 International Hospital Federation, 3.38, 5.32 and I979), I 1.49 International Instirute of Applied Systems Analysis, Joint Inspection Unit (United Nations), 2.I6 I 3· I8 Jordan, 5.29, 5·75, 8.45 International Labour Organisation (ILO), 5·73, 5·75, 5.8I, 6.48, II.37 International Organization for Cooperation in Health Care (Medicus Mundi), 5. I 3 Kala-azar, 9·7I International Organization against Trachoma, 9.148 Kenya, 8.45, 9.I2, 9.7I, 9.224, 10.9 International Paediatric Association, 6. I 2 Khat (Catha edulis), 7.29 International Pharmacopoeia, 8.23-8.24 Kiribati (formerly Gilbert Islands), 5.I2, 5.63, 6.p, International Planned Parenthood Federation, 6. I 2, 6.48 9·75 International Radiation Protection Association, I I. 31 Kuwait, 7.8, 7· I I, I0.2, IO. I4

255 THE WORK OF WHO, 1978-1979

Laboratory animals, breeding and management, advisory panel, Eastern Mediterranean Region, 9.23 9.I66-9.I67 chemotherapy and chemoprophylaxis, 9.32, 9·34, 9·35 Laboratory technicians, 7.29 coordination between countries, 9.24, I 5. I 5, I 5.119 Laboratory technology and services, 5.20, 8.38-8.48, intercountry border meeting, I 5. 78 9·52· 9·I35-9·I36, IO,IIO, I2.S4, I5·3S, I5.I59 programme financing, 9.36, I5.119 training of personnel, S.39, S.44, S.45-S.46, 9·I36 drugs, production and distribution, I 5. 77 see also Collaborating centres ; Microbiological resistance of parasites, 9.25, 9.26, 9.2IS, I5.76, laboratories ; Drugs, quality control I 5. I72 Lao People's Democratic Republic, 5.34, S.46, 9.29, trials, 9.32, 9·35, 9.2I5-9.2I6 14·23 epidemiology, 9.22, 9·35, 9.217, I5.I5 Larva migrans, 9· I 5 I immunology, 9·33-9·34, 9.2I5-9.2I6, 10.94-Io.95 Larvicides, 9·51, 9·17S, 9.ISo research, 4.31, 9·3I-9·35, 9.2I5-9.2IS, 10.9, Io.2S, Larvivorous fish, 9· 3 5, 9· I 93-9· I 94 I2.1IO, I5·76 Latin American Association of Schools of Public review, 9·3 I Health, I2.32 revised strategy, I.IS, 9.22, 9.2I7, I5.I5, I5.76 Latin American centres for educational technology task force, African Region, 9.23 in health, I2.32, I2.7S training, 9.24, 9·30-9·31· 12.S5, I2.IIO, I2.II5, I5.76 Latin American Centre for Perinatology and Human vaccine, trials, 9·33· 9.2I5 Development, 4.22, 6.17 vector control, 9·35, 9·I76, 9·I97, I5.S5 Latin American Federation of the Pharmaceutical biological, 9·35, 9·I93-9·I94 Industry, S.7 insecticides, 9·35, 9·173, 9·I76, I5·77 Latin American Programme of Educational Develop­ resistance of vectors, 9.25, 9·35, I5.I72 ment for Health, I2.I5 spraying equipment, 9·35 League of Arab States, 3.56 Malaysia, 2.20, 5·49, 5·73, 5.76, 7.23, S.45, S.46, 9.29, League of Red Cross Societies, 3.3S, 3·43, 3.50, S.39, 9•49, 9.53, 9.20I, II.S, 12.52, I4.7, I5,I6I S.45, S.47 Maldives, 3·45 Lebanon, 1.31, S.44, 9.25, 9.2S Mali, 5.25, 9·51· 9.53, 9.ISo, I5.I6 Legionnaires' disease, 9.S6 Malnutrition, 4.II, 6.32, 6.35, 6.4o-6.4I, 6.7S, 6.S9, Leishmaniasis, 9.7I-9.72 I5.69, I5.II2 research, 9.22S Malta, S.4o Leprosy, 9.87-9·98, I5.3S, I5.39, I5.So, I5.170 Management, see Health management ; Programme of BCG trial, 9.S9 WHO, management chemotherapy, 9.S9 Manpower development, management and planning, drug trials, 9.S9, 9.230, I 5.So, I 5. I70 3·30, 3·55. 5.I2, 5·I3, 5·I9, 5·25, 5·34, 6.37, 9·4, combined leprosy and tuberculosis activities, 9·75, 9.I6I, I0.70, 12,1-12.136, I5.20, I5•45-I5•47, 9·93· IH7 I5.66, I5·9I-I5·97· I5.I32, I5.I46-I5.I47, immunology, 9.229 I5.I7S-I5.IS4 research, 9.SS, 9.S9, 9.229-9.230, I 5.So community-oriented educational programmes, training 9·93, 9·97, I5.I70 I2.57-I2.62, I5·93 Leptospirosis, 9· I 52 continuing education, I2,2S, I2.30, I2.34-I2.3S, Lesotho, 7.4, 7·49 I2.4S, I5.66, I5.I32, I5,ISI Liberation movements recognized by OAU, health interregional seminar (I979), 12.34 cooperation, 1.30, 3·54-3·56, I5·5 curricula, I2.2I, 12.3I, 12.79, I2.SI, I2.S2, I2.92, Liberia, 9.52, 9·I99 I5·93> I5·17S Libraries, see Health literature services ; Medical information service, I2.I2, I2.63-I2.64 libraries integration with health services development and Libyan Arab Jamahiriya, 7.S, 9·I53, I2,II5 primary health care, I2.2, I2.4-I2.6, I2.I3, I2.14, Life table and mortality analysis, I 3. 2 7 I2,I5-I2.I9, I2.46, I2.6o, I2.90, I5.20, Liver cancer and other chronic liver diseases, 4· 3 5, 10.9, I5·9I-I5·92, I5.I36, I5,I5S IO.I5, Io,2o, I0.2I, I0.26-Io.27 international migration, I2.39-I2.40, I5.I79 Long-term planning, 2.9, I2.3 medium and long-term programme of WHO, I2.3, 12.7-12·53 Macao, 9.29 interregional meeting of nationals and WHO staff Madagascar, 7.27 (I 97S), 12.S Malaria, 3.52, 3.53, 6.5 2, S.4o, 9.21-9•37, 9·43, 14.23, revision, I2,IO I5.I5, I5·75-I5·7S, I5.S5, I5.119, I5.I72 research, 3.30, 4.I2, 4.27, I2.I3, I2.I7, I2.6o, I2.S9, advisory committee (headquarters), 9.22 I5·92, I5.I45, I5,I47 INDEX

Manpower development (continued) research, 4.7, 4.27, 7.32, 7·37-7·47, I5.II5, I5.I65 training of planners, I2.20, I2.22, I2.33 training, 7.3, 7.5, 7.8, 7·31· I2.88, I2.I02-I2,I09, see also Auxiliary health personnel ; Educational I 5. I65 technology ; Teacher training Mental retardation, 7.Io Manual of basic techniques for a health laboratory, I2,84 Mesothelioma, IO.I9 Manuals, technical, 2.7, 3·43, 5.20, 5.24, 5.38, 6.40, 6.5I, Metabolic disorders, I 5. I 73 6.99, 6.IOI, 7.II, 8.33, 8.47, 9•77• 9·I34, 9.I89, Mexico, 4.I9, 4.2I, 5.2I, 5.24, 5.26, 5.6o, 7.5, 7.I5, 7.2I, 9·I97, I0.6, I0.46, I0.74, I0.87, I2.83, I2.84, I2.88, 8.30, 8.35, 9·75, 9.76, 9.126, 9.I8o, I2.98 I2.I23, I2.I33. I2.I34. I5.I2 Microbiological laboratories, prevention of accidents see also Guides, technical and infections, 9.6-9.8 Maternal and child health, I.I9-I.20, 3.I6, 6.13-6.31, Microbiologists, training, I 5. I 20 I5.I3, I5.67, I5.I63 Middle East, I. 3 I information systems, I5.67 Midwifery, I2.17, I2,24 medium-term programme, Europe, 6.30 see also Nursing ; Traditional birth attendants Migrants, health of, 5.Io, 5.69 research, 6. I 5 risk approach, 6.I5, I5.I3, I5.67, I5.I6I Migration of health manpower, IZ·39·IZ.4o, I5.I79 training, 6.27, I2.27, 12.94, I2.95, I2.I30, I5.66, Milk, vitamin A enrichment, 3.25 see also Breastfeeding I5.67, I5·93 Mauritius, 9.24 Molluscicides, 9· I 86 Mongolia, 7.6 Measles, immunization and vaccine, 8.30, 8.3 I, 9.209 Monkeypox, 9.I7, 9.I8 Measurement of levels of health, I 5.109 Morocco, 8.45, 9.25, 9.27, 9.I86 Medical assistants and auxiliaries, I 5. I So Medical care, see Health care Moxibustion, 5·59 Medical education, I2.I6, I2.I9, I2.38, I2.6I, I2.62, Mozambique, 3·45, 3.48, 9.63 Mycoplasma, 9.I68 I2.63, I3•7> I3.8, I5,I32, I5.I8I Mycotic zoonoses, 9· I 5 I curricula, I2.37, I2.6I, I2,I07, I2,II4 Myocardial infarction, I o. 51, 10.5 8 medical textbooks, provision of, 9.77, I2.86 Medical libraries, 2.50 regional, 4.22, I 3.3I, I 3·33 Narcotic drugs, 7.26-7.30 Medical records, I2.I23, I2.I32, I3·9-I3.IO Nasopharyngeal carcinoma, IO.I5, I0.29 Medical schools, meetings of deans and directors, I2,I9 National coordinators, 1.9, 3.22 see also Medical education National staff, involvement in WHO programmes, Medicinal plants, 1.24, 5·52, 5·55, 5.56, 5.6o, 5.63, 5.64, 2.6I, I5,I37-I5.I39 8,I6, I5.I66 Nepal, 2.I6, 3·5o, 9.26, 9.36, 9·75, 9.76, 9.96, 9.I28 Mediterranean basin, conference for defence against Netherlands, 3.II, 3·49, 9.2I2, IO.I04, II.28, I5.85 natural disasters (I 979), 3.42 Neurological disorders, 7·35, 7·42-7.47 Mediterranean sea, pollution, I 1.43, I4. IO study group and task force on peripheral neuropathies Mediterranean zoonoses control programme, 9, I 53, (I979), 7-46 9·I 55 symposia, 7·47 centre, 3·I9, 9·I53 training, I2.I04, I2.I05 Medium-term programming, z.z9-Z·3S, I2.3, 12.7-I2.I3 New Hebrides, 9· 75 regional, 2.32, 2.33, I5.II2, I5.I50·I5,IJI New Zealand, I0.5I, I5.I79 Membership of WHO, I4.I (Annex I) Nicaragua, 4·I9, 7·50, 9.25, I2.I5 Menarini Foundation, 7·45 Niger, 3.48 Meningitis, see Cerebrospinal meningitis Nigeria, 7.38, 9.I8, 9·31• 9·35, 9·52· 9·53· 9·174, 9.178, Mental health, 6.u, 7·1·7·55, I3.29, I5,I8, I5.73, 9.I8o, Io.58, I2.96, I2.I35, I5.I6 I5.I05, I5.II5-I5,II6, I5.I65 Niue, 9.2oi community services, 7.3, 7.6, 7·9· I 5.II 5, I 5. I65 Nomenclatures, I0.59, I3·53 pilot studies, European Region, 7·7 Noncommunicable diseases, lo.I-IO.IIZ, I5.I7, I5.38, drug treatment, 7·33-7·36 I 5,86, I 5, I73-I 5, I74 minimal list of drugs, 7. 35 chronic, ..:ommunity control, Io.6o-Io.6I, Io.62, I 5.86 expert panel, African Region, 7.49 Nongovernmental organizations in official relations information systems, 7.6, I5·73 with WHO, 3.6-3.8, 7·47, 7.48, (Annex 3) integration in primary health care, 7.3, 7.6, I5.73 Nonverbal communication, I2.89 medium-term programme of WHO, 7.I-7.2, 7·54 Norway, 7·49, Io.58, I5.I23 national and regional coordination groups, 7·48-7.52, Nosocomial infections, I 2. 5 I I5.I8, I5.73, I5.I65 Nuclear energy, 10.92, II.37 THE WORK OF WHO, 1978--1979

Nuclear medicine, Io,86-Io,89, I2.I34 Ad Hoc committee, Eastern Mediterranean Region, Nursing, I2.I7, I2.24, I2,39, I5.I46, I5.I8o I5.I39 mental health, I2,Io8, I2,I09 Organizational studies by the Executive Board, r.9-r.I 1, primary health care, I2.47 I2,29 role of nurses in control of hospital infections, I 2. 5 I Orthopaedic and orthotic services, see Disability role of nurses in family health programmes, 6.97 prevention and rehabilitation textbooks and other educational materials, I2.86 Oswaldo Cruz Foundation, IO.I03, IO.I05 training, I2,47-I2.51, I2.74, I5·93 teacher training, I 2.48 Nutrition, 3.24, 5.I6, 6.5, 6.p-6.45, I5.68-I5.69 P AHO, see Pan American Health Organization integration in primary health care, 6.35, I5.I2, I5.68, Pakistan, 4·33, 5·75, 7.20, 7.23, 9,22, 9.25, 9.28, 9·75, I5.I64 I2. I 3I national food and nutrition policies, 6.3 3, I 5.69, Palestine Liberation Organization, 3.56 I5.I64 Pan American Center for Human Ecology and Health, research, 4.6, 4.7, 4.II, 4,22, 4.25, 4.31, 6.40, 6.43, 4.22, II.II, II.4I, I5,4I I5.I2, I5.68, I5·98 Pan American Center for Sanitary Engineering and surveillance, 6.38-6.39, I5.I2, I5.I64 Environmental Sciences, 4.22, II. II, II.4I, I5.4I training, 5.7, 6.37, I5,I2, I5.I64 Pan American Federation of Associations of Medical WHO research development and training programme, Schools, I2.32 6.34 Pan American Foot-and-Mouth Disease Center, 4.22, 9·I52, 9·I63, I2,II3, I5·53 Pan American Health Organization (PAHO), I5.24 OAU, see Organization of African Unity I5-57 Occupational health, 5·67-5.81, ro. I9, ro.22, I 5. 126, publications, I 3·43 I5.127, I5,I60 Pan American Sanitary Bureau, see Regional Office for criteria and standards, 5.77, 5.8I, Ir.36 the Americas early detection of impairment, 5. 79 Pan American Zoonoses Center, 4.22, 9·I52, 9.I63, integration into general health services, 5.7o, 5·73 I2,II3, I5·53 research and training, 5. 76, I 2. roo Panama, 4.22, 5.8, 7.II, 9.72, I5.47 centres, African Region, 5. 7 I Papua New Guinea, 5·34, 6.52, 7.II, 7·I9, 8.40, 8.46, see also Working populations, health of 9,29, 9·75, 9.85, 9·97, II.8, I2,46, I2,52 Offset publications {WHO), I3·39 Paraguay, 9.68 Oman, 3.27, 7.8, 9.25, 9.28, II,7 Parasitic diseases, 9·21·9·73 Onchocerciasis, 9.48, 9·5 I-9·52 research, 9·4I, 9.42, 9·43, 9·73, 9.233 chemotherapy, 9.51, 9·52, 9.22I training, 9·43,_9.72, I2,85 research, 9·5 2, 9.22 I-9.223 see also Special Programme for Research and Training vector biology and control, 9.51, 9·55-9·56, 9.I8o, in Tropical Diseases 9.I87 Parasitologists, training, I 5. I 20 Volta River basin area, control programme, 9·54-9.61, Particulate matter, health hazards, 5. 78 I 5. I6 Peace, health and, r.29 financing, 9· 59-9.60 Perinatal care, 6.17 Oncology, see Cancer, research Perinatal mortality, I3.27, I5.II2 Operational research, I3.I5, I3.I6, I5.93 Periodontal diseases, ro.7o, I0.75, I5.I74 Ophthalmology, 9·I47 Personnel for health care : case stlldies of educational pro­ Oral health, 10.67-10.76, I5.I25, I5.I74 grammes, I2.57 auxiliaries, I 5. I 2 5 Pertussis, 9·99 training, ro.72, Io.76, I2.25, I2.I33, I5.I46, I5.174 vaccination and vaccines, 8.3I, 9·99, 9.209 Organization of Mrican Unity, r.3o, 3·54, 9.66, 9.67, see also DPT vaccine 9·I54, I5·5 Peru, 4.I9, 7.20, 9.25, 9.68, 9.I67, II.44 International Council for Trypanosomiasis Research Pesticides, 9·!74, 9.187-9•191 and Control, 9.66 equipment for application, 9·!75 Organization for Coordination in the Control of health hazards, 5.68 Endemic Diseases in Central Africa, 9.63 residues, I I.49 Organization of Petrol Exporting Countries, 9·59 safe use, 9.I73, 9·I90 Organizational and related meetings, (Annex 2) training, 9.I89, 9·I9I, I2.Ioo, I2,I35 Organizational structure of WHO, (Annex 4) see also Insecticides ; Molluscicides ; Rodent control re-examination in the light of functions, I .9-I, IO, I,32 and rodenticides INDEX

Pharmaceutical production, 1.24, 8.I5, 8.q reports of regional directors, 2. 37 regional and national, 8.2, 8.6 Programme budgets (WHO), I 5-5 I Pharmaceuticals, see Drugs for I980-I98I, 2.35, 2.36 Pharmacists, training, 8. I 9 policy and strategy, 1.6, 2.28 Pharmacology, clinical, 8.28 for I982-I983, I2.Io see also Psychopharmacology Programme Committees Philippines, 2.59, 3.38, 3.53, 5.2I, 5.30, 5·34, 5·49, 5.68, Global Programme Committee, 2.33 5, 76, 9.29, 9•42, 9.220, II,8, I I,4I, I4. 7 Programme Committee of the Executive Board, Physiotherapy, training, 5.26 1.6-1.8, 2.31, 4.2-4.4 Plague, 9.105, 9.I84, 9.I85 regional programme committees, I 5. I03 Planning, see Environmental health, national planning ; Programme of WHO, general development and manage- General Programmes of Work; Health planning ment, 2.28-2.61, I5.I02-I5,I03, I5,I50-I5.I52 and programmes ; Long-term planning ; Man­ information systems, 2,46-2.6 I power development, management and planning ; trends and priorities, I.I7-I,28 Medium-term planning ; Programme of WHO see also Evaluation ; Regionalization Pneumoconiosis, IO.I9 Prophylactic substances, 8. I-8.48 Pneumonia, 9.82, 9.Ioi see also Drugs ; Immunization ; Pharmaceutical Poland, 5·74 production Poliomyelitis, 9· I 20-9. I 2 I Prosthetics, 5.25, 5.27, I2,I27 immunization and vaccines, 8.30, 8.3I, 8.35, 9.I2I, Protein-energy malnutrition, 6.40 9,209 Protocol for the Protection of the Mediterranean Sea Pollution, see Air pollution; Coastal pollution; Environ­ against Pollution from Land-based Sources, draft, mental pollution; Soil pollution ; Water pollution I4,IO Portugal, 5·74, 8,40, I1.25, I4.7 Psychiatry, 7·33-7·36 Postgraduate training, 4.2I, 5.25, 5·59, 9.24, 9·43, 9· I62, training, 7.6, I2.I04, I2.I05 IO.I2, I0,63, II.45, I2,37, I2.6I, 12.97, I2.I04, Psychopharmacology and psychopharmacotherapy, I2.I06, I2,I07, I2.II3, I2,II4, I5.94, I5,I32 7·33-7·36, I2.I05 Poxviruses, research, 9.I6-9.I7, 9.20 PS)•chopharmacolog)' bulletin, 7.36 Pregnancy and its outcome, 6.q, 6.I8, I5.67, I5.II2 Psychoses, affective, 7·34, 7·35, 7·37, 7.40 termination and abortion, 6.25, 6.84-6.85, 6.92 Psychosocial factors and health, 4.II, 5.69, 7.rr, testing, 8.36 7·37-7·41, I2.I02 Preventive and social medicine, 5.6I Psychotropic substances, 7·25-7·30, 7·35, 7.36 Public health in Europe, I3.42, J5.I33 Primary health care, 1.2, I.I3, 3.I-3.2, 3.5, 3.II, 4·I5, P11blic Health Papers, I3·39 5.6-5.13, 5.29, 5·33, 5·34, 5·35, 5.36, 6.I, 6.28, Public health services, see Health services 6.35, 6.57, 8.38-8.39, II.I, I2,2, I2.4-I2.5, 12.45, Public health training, 1.9, 2.20, I2.29, I2.3o, 12.32, I3.58-I3.6I, I5,8-J5.IO, I5.26, I5.58, I5.6I, I5.70, I5.7, I5,IO, I5.I32 I5.7I, I5.I08, I5.I36, I5.I48, I5,I57 Mrican centre, I5·7 programme financing, 3.Io, 3.12, I5.56 schools, meetings of directors, I 2.6o International Conference (I978), 1.2, 3·!7, 5.I, 8.2, Public information I3.I, 13.56-13.62 12.4, I5•9 joint study on community involvement, UNICEF/ Publications, WHO programme, I 1.31, 13·34-13.47 distribution and sales, I 3. 54-I 3. 55 WHO, 6.46 records and statistics, I3.9, I3,I8 printing costs, I 3.46 I3.42-I3.44, I5,I33-I5,I34 role of nurses and midwives, 12.47 regional publications, see also Drugs, essential review, I3.36 Primary health care in Europe, I5.Io8 translation, I3.43, I3.46, I3.47, I4.2o Publications and Documentation Service, PAHO/WHO Primary Health Care Fund, 3.Io (Mexico), establishment, I3.43, I4.20 Primary health care workers, I2.27 training, 5.7, 5·33, 6.50, 7.3, I2.4-I2.5, I2.32, I2.4I, 12.42-12,56, I2.86, 12.94•12,98, I2.I23, I3.IO, Qatar, 5·75 I5.IO, I5,72, I5.92 Quality control, see Biologicals ; Drinking-water; Primates, nonhuman, 9.I67 Drugs ; Water, quality control Profiles, programme and project, 2.27, 2.47, 2.48 Programme budgeting, 12.8 national, 2,II-2.I2, 2,37, 2,38 Rabies, 9.Ip, I5.83, I5.II8 in United Nations system, 3·4 vaccines, 9· I 52, I2. II 3, I 5.83 in WHO, 2.35·2.39, 2.54 wildlife rabies, joint FAOjWHO programme, 8.II3 THE WORK OF WHO, 1978-1979

Radiation health and protection, Io.82, II.34, II.37, Republic of Korea, 5.I2, 5.34, 5·49, 5.76, 9.29, 9·75, I5·44 9.20I, IO. I 5 environmental radiation, I I. 3 7, I I. 3 9 Research, I. 7, 4.1-4·39, 5.Io, 5·55, 6. 7, 7·45, I 5.2I, I 5 .46, ionizing radiation, 10.90-I0.92, II.39 I5.80, I5.98-I5.IOI, I5.I07, I5.III, I5.I44-I5.I45, monitoring, II.37, II.39 I5.I55-I5.I56 training, 10.9I ethical aspects, 4· I 8 Radiation medicine, zo.77-I0.89, I 5·44 financing, 4.3, 4.6, 4· I 3, 4.24 diagnosis, 10.78-Io.82 information systems, 4.2, 4.6, 4.22, 9.238, q.I22 therapy, I0.83-I0.85 legal aspects, I 4· I I training of radiographers and radiological technicians, medium-term programme, 4· 5 I0.80, I2.II8, I2.I34 regionalization, I. q, 4.2, 4.9, I 5.2 I, I 5.98-I 5.99, Radiological equipment, standard dosimetry, I0.84- I 5. I07 I0.85 training, 4.3, 4.I8, 4.20-4.2I, 4·24,9.235-9.237, I5.99, see also X-ray equipment centres, 4.I4, IO.I03, IO.I04, IO.I05, I5.I2, I5.29, Reagents, laboratory, 8.36, 8.39, 8.42, 9.72, 9·I3 I, 9·I35, I 5.4I 9.I68, 9.I69, IO.Ili grants and awards, 4.8-4.9, 4·I4, 4.20, 4.24, 4.36, WHO programme, 9· I 37 9.2I3, 9.235, 9.237, I2.II6, I5·99 Refugees and displaced persons, I.31, 3·47, 3.50, 3·52, IARC programme, 10.I6-I0.39 see also Health services research; Human reproduction, 3·53, I4.23 research ; Operational research ; Tropical Regional Committee for Africa, 1.30, 3·33, 6.30 diseases, research technical discussions, 6. 56, I 5. 3 Research coordination, 4.2, 4.6-4. 7, I 5. Ioo Regional Committee for the Americas, I.I8, 3·33 technical discussions, 8. 7 Respiratory diseases, 4.37, 5.So, 6. I I, 9.82-9.86, Regional Committee for the Eastern Mediterranean, 9•II3-9·II5, I5.II2, I5.II8, I5.I55 chronic, I0.65, Io.66 1.22, 3·33, I5.I39 technical discussions, I .20, 6. 30 Rheumatic diseases, I 5. I 24 Regional Committee for Europe, 6.30 Rheumatic fever, 10.50 technical discussions, 12.36, I5.I24, I5.I32 Rheumatic heart disease, 10.50 Regional Committee for South-East Asia, 1.28, 3·33 Rheumatoid arthritis, 5.6I, Io.65 technical discussions, 8.8 Rickettsial diseases, 9· I 31 Regional Committee for the Western Pacific, I.I8, 3·33 Rift Valley fever, 9· I 30 technical discussions, 9.85 Risk approach for maternal and child health care, 6. I 5 Regional committees, I. I, 1.26, 3·3 Rockefeller Foundation, 9· 7 3 Regional Director for the Western Pacific, procedure Rodent control and rodenticides, 9· I 84-9. I85, 9· I99, for nomination, I4·9 I2.II5 Rodent Control Demonstration Unit (Rangoon), 9.I84 Regional Office for Africa, 2.56, 3.38, 3.40, 8.37 Romania, 9.81 Regional Office for the Americas, I.I3, 2.57, 3.31, 3.38, Rural development, I 1.27 3•4I, I3.2, I4•I5 water supply and sanitation, I 1.2, I 1.5, II.8 reorganization, I 5.28-I 5.29 Rural health, 3.26, 5·34, 8.38, 12.34, 12.35, 12.44 Regional Office for the Eastern Mediterranean, 2.59 Rwanda, 3.48, 7·49 Regional Office for Europe, I.2I, 2.58, 8.9, 8.28, 8.43, I3.2, I4.8, I4.I9 publications, I 3.42 Regional Office for South-East Asia, 2.59 Samoa, 9·53 Regional Office for the Western Pacific, 2.59, I4.9, I4.I8 Sanitary and public health engineering, training, Regional Offices, (I5.I, Map) I2.I2I-I2.I22, I5.93 review and reorganization of administrative struc­ Pan American centre, 4.22, I I. II, I I.4I, I 5.41 tures, I3.2 Sanitation, 1.5, 3.I6, II.I4-II·3o, I5.40, I5.I76 staff training, I 4· I 3-I 4· I 5, I 4· I7 integration in primary health care, II.5, I 1.22, I 1.23, Regionalization of staff and programme activity, 4.2, II.27 I3.42 international decade (I980-I990), I.5, 3·I9, I 1.2, Regions of WHO, (Ip, Map) II.I4-II.2I, Il.24, II.25, II.26, II.30, I4.I4, Rehabilitation, see Disability prevention and rehabilita­ I5·40, I5·I76 tion see also Environmental health; Sewerage; Wastes Rehydration, 4.31, 5·17• 5.20, 9·I4I, I5.8I disposal; Water supplies Reporting system of WHO, 2.48 Saudi Arabia, 7.8

z6o INDEX

Schistosomiasis, 3.27, 9·39-9·46 financing, 6. I03 research, 4.36, 9·45-9·46, 9.I86, 9.2I9-9.220 research training, 6.63-6.70 training, 9· I 86 grants, 6.64-6.67 Schistosomicides, 9·4 I, 9· I 51, 9· 2 I 9 support to institutions, 6.64-6.65 Schizophrenia, 7·34 Special Programme for Research and Training in School health, 6.28 Tropical Diseases, 2.49, 3·I9, 4.6, 4.26, 9.31, 9.40, Scientific Group on Acute Viral Respiratory Diseases 9·45, 9·52, 9.66-9.67, 9·70, 9·87, 9.I8I, 9·213-9·239, IO.II2, I2.II6 (I979), 9·84 Senegal, 7.3, 9·93, 9.I8o, I5.I6 management and finance, 9.238-9.239 Sera, international control, 8.48, 9.I68, IO.I09 scientific working groups, 9.2I4, 9.229, 9·231-9.234, reference banks, 9.69, 9.227 9· 2 37 Sewerage, I 5.87, I 5.176 support to institutions, 9·235-9.237, I2.II6 Sexually transmitted diseases, 9.107-9.109, I 5. I I 8, Sports medicine, Io.n I5.I2I, I5.I69 Sri Lanka, 2.I6, 3·45, 5·73, 7.6, 7·51· 9.26, 9.36, 9.53, research, 8.98, 9.Io8, 9.I23-9.I24, I5.I69 I0,2, IO.II, 12.30 training in control, 9.Io7, I2.III St Vincent, 3·49 Seychelles, 14· I StaffofWHO, I4.I2-I4·17 SIDA, see Swedish International Development recruitment, 1.28 Authority training, I4.I3-I4·17 Silicosis, I0.97 women, 1.28 Singapore, 9.29, 9·75, I0.27, 10.58 Statistics, J3.I, 13.3-13.29 Single Convention on Narcotic Drugs, 7.26 development of services, I 3. 5- I 3. 14 Sixth report on the world health situation, I3.25 dissemination by WHO's central services, I3.25-I3.29 Smallpox, eradication, 9.I, 9.3, 9·9-9·20 establishment of national committees, 13· II certification, 9· 5, 9· I o-9. I 3 information systems, I 3· I I-I 3· I4 Global Commission, 9.Io, 9.II, 9·I3, 9.I8, 9·I9 interregional conference on teaching of medical vaccination, 9· I 9-9.20 students, I 3. 7 discontinuation, 9· 5, 9· I 9 (Fig. 9· I) methodology, 6.II, I3.I5-I3,I9 Smoking and health, 1.22, 6.5 I, 7· I8, I0.2o, I0,22, mortality and morbidity data classication, use by lay I0.5 5-I0.56 (nonmedical) health personnel, I 3.2 3 Social security, 2. 9 training, I2.II3, I2,I24-I2.126, I2.I31, I3·5-I3.IO, Socioeconomic development and health, interrelation­ I3.I4, I3.22 ship, 2,Io, 3.22, 6.28, 6-48, 9.58, 9.234, I2.26, I3.6I, see also International Classification of Diseases I5,2-I5.3, I5.26-I5.27, I5.32, I5.60, I5.86, I5,II2, Sterility, see Infertility I 5, I78 Sterilization, 6.25, 6.87, 6.97, 7.38 Soil pollution, I 5·43 Steroids, 6. 79, 6.88 Solomon Islands, 9.29, 9·75, 9.I76, I4·7 Streptococcal infections, 9· IOI-9. I02 Somalia, 9.9, 9.I2, 9·75, 9.I93, II.25 Stress, 7·37 South Pacific Commission, 3.23 Stroke, Io.42 South Pacific Countries/Areas, Conference of Ministers Studies in drug utilization, I 5. II 7 of Health on Technical Cooperation in Phar­ Study Group on the Application of Advances in maceutical Supplies (I979), 3.23, 8.I2 Neurosciences for the Control of Neurological South Pacific pharmaceutical service, 8.12, 8.I9, I5.I66 Disorders (I977), 7.42 South-East Asia Region, 3.50, 4.23-4.26, 5·9, 5.17, 5.27, Study Group on the Financing of Health Services (I977), 5.38, 5.6I, 5·73, 6.Io, 6.26, 6.47, 7.6, 7.Io, 7·5I, 2,12, 5·38 8.8, 8,40, 8.45, 9.26, 9·95-9·96, IO,II, II.23, II.44, Study Group on Limits in Occupational Exposure to I2.I9, I2.23, 12.5o, I2.6I, I2.97, 1s.5s-15.1o3 Heavy Metals (I979), 5·77 Southern Africa, 1.30, I5.2, I5.I8 Sudan, 3.26, 4.31, 5·3I, 5.68, 7.3, 7.8, 8.44, 9.30, 9.36, Spain, 5. 74, I0.22 9·43, 9·52, 9·53> 9·62, 9·I32, 9·I33, 9·173, 9·176, Spanish, translation of publications and documents, 9·I96, I2.89, I5.I37, I5.I48 I3·43, I4.20 Supplies and equipment, provision of, 5,20-5 ,22, 8.40, Special Programme of Research, Development and 9.208, 9.2I0, I4.2I-14.23 Research Training in Human Reproduction, 2.49, costs, I4.22-I4.23 4.26, 6.57-6.103, 7.38, IO.II2 see also Emergency assistance ; Equipment coordination, 6.I02 Suriname, IO.I04 dissemination of information, 6.Ioo-6.Ioi Swaziland, 7.14, 7·49. Io.9, I0.27 programme resources, 6.6I-6.62 Sweden, 3.II, 8.24, 9.212, Io.I6, IO.I9, I0.58, II.40

261 THE WORK OF WHO, 1978-1979

Swedish Agency for Research and Cooperation with Tonga, 2.20, 5.76, 8.40, 9·75, 12.46 Developing Countries, 6. r 2 Toxicology, see Chemicals; Drugs safety and efficacy; Swedish International Development Authority (SIDA), Food safety and hygiene ; Pesticides, health hazards 6. 19, 9.26, II,24 Toxoplasmosis, 9· r 5 r Switzerland, 3.rr, 3.48, 7.14, 9·59, ro.58, ro.ro5, ro.rr2 Trace elements, in cardiovascular diseases, ro. 58 Syrian Arab Republic, 3.27, 7.8, 9.25, 9.28, 9.176 Trachoma, 9.149 Systems analysis, 13.15, 13.16 Traditional birth attendants, r2.53-12.56 Traditional health workers, r 5. 72 Tanzania, United Republic of, see United Republic of training 5·55-5·56, 12.44 Tanzania Traditional medicine, 5.9, 5.34, 5·so-s.66, 7.6, ro.8, Teacher training, 5.7, 6.27, 12.48, 12.69-12.81, 12.88, 15·72> 15·73 bibliography (P AHO), 5.Go I2.I30-I2.I33, 13.6, 15.10, 15.95, 15.182 handbook for health administrators, 5.66 centres, I2.7o-r2.72, 12.77, r2.8o, 12.81 Teaching for better learning: A guide for teachers of health research, 4.31, 5·55, 5.62, 15.72 study tours in China, 5. 58, 5. 59 staff, 12.82 Traffic accidents (road), 4.27, 5.28, 5.29, 5.30, 5·37, Teaching/learning materials and processes, 6.54, 9.205, !0,2!, 15.105, 15.III 12.48, 12.57, 12.71, 12.75, 12.82-12.89, postgraduate course on traffic medicine (1978), 5.25 I2.I34-I2.I36, 15.96 Treponematoses, endemic, 9.rro participation of students, 12.75 Trichinellosis, 9· r 5 r see also Textbooks Tropical diseases, research and training, r 2. 85, r 5. r 55 Teams, see Health teams special programme, 2.49, 3.19, 4.6, 4.26, 9·3 r, 9.40, Technical cooperation, 12.65, I3.r6-r3·I7, 13.19, 13.23, 9·45, 9·52> 9.66-9.67, 9.70, 9.87, 9.I8I, 1 4·7 9.213•9,239, IO,II2, I2.II6 among developing countries, 1.13, r.r5, 3·31·3·35, management and finance, 9.238-9.239 II,5, I5·4-I5·5> 15.38, 15•48-!5·49, 15.64, 15.94, scientific working groups, 9.2 14, 9.229, 9.23 r-9.234, I5.140-I5.I4I United Nations Conference (1978), 3·32 9.237, IO.II2 support to institutions, 9·235-9.237, r2.rr6 direct technical services, 2.49 Trust Territory of the Pacific Islands, r 2. 38 information exchange, r 5·49 pharmaceutical supplies, 3.23, 8.r2 Trypanosomiasis, 9·2-9.70 inter-agency task force, 8. I7 research, 9.64, 9.66, 9.224-9.227 WHO's role at the country level (organizational drug trials, 9.224, 9.227 study), 1.9-1. IO seminar, FAOfWHOfOAU (r978), 9.66 Technical discussions, at Health Assembly, r.r2-r.q, vector control, genetic, 9.183 8.r insecticides, 9.65, 9.r8r-9.r82, 9.199, 9.226, r2.rr5 at regional committees, r.r5-r.r6 see also Chagas' disease Africa, 6.56, 15.3 Tsetse fly, 9.r82-9.r83, 9.199, 9.226, r2.rr5 Americas, 8. 7 Tuberculosis, 9·74"9.81, 15.79, I5.rr8, I5.I7I Eastern Mediterranean, 6.30 BCG vaccination and vaccine, 8.33, 9.78, 15.79, 15 .r7r Europe, 12.36, 15.124, 15.132 chemotherapy, 9.76, 9·77 South-East Asia, 8.8 combined leprosy and tuberculosis activities, 9·75, 1 Western Pacific, 9.85 9·93, 5-37 integration of services in general and primary health Technical Report Series, r 3.41 Terminology, rr.p, r3·52-13.53 care, 9·75, I5.I7I Tetanus, 9·99-9· roo research, 9· 78, 9· 79 vaccination and vaccine, 8. 33, 9· roo training, 9.76, 9.77, r5.I7I tuberculin testing, 9.80 see also D PT vaccine Textbooks (medical and nursing), 9.77, 12.86 Tumour-associated antigens, ro.3o-ro.3 r Tumours, classification, 9.165, ro.4 Thailand, 2.20, 4.23, 6.97, 7.6, 7.rr, 7.14, 7.20, 7.21, Tunisia, 9·43 7· 27> 7·51> 9·22, 9.26, 9·31, 9·32, 9.!28, 9·!73, 2 9.215, !0.2, IO.II, 10.76 Turkey, 6.97, 9.21, 9·2 , 9.25, 9.27, 9.36, 9.153, 9·!73, The learner, r2.8o 9·!76, II.6, 11.25, 14.23, 15.II9, 15.131 The primary health care 2vorker: Working gwde, gmdelines Tuvalu, 9·75, 14.7 Typhus, 9.185 for training, guidelmes for adaptation, r 2-42 Therapeutic substances, 5.47, 8.1-8.48 Thrombosis, ro.53 Uganda, 3.48, 9.62, 9.63, ro.9, ro.28 Togo, 9·54 Ulcers, gastroduodenal, r 0.2 r INDEX

UNCTAD, see United Nations Conference on Trade United Nations Educational, Scientific and Cultural and Development Organization (UNESCO), 6.47, 6.48, I 1.43, I5 .89 UNDP, see United Nations Development Programme United Nations Emergency Operation (UNEO), 3.48, UNDRO, see United Narions Disaster Relief Coor- I4.23 dinator United Nations Environment Programme (UNEP), UNEO, see United Nations Emergency Operation 3·44, 5.68, 5.8I, I0.9, I0.27, II.30, II.3I, II.36, UNEP, see United Nations Environment Programme II.38, II.40, II.4I, II.42, II.43, II.50, I3.40, I4.9 United Nations Fund for Drug Abuse Control UNESCO, see United Nations Educational, Scientific, (UNFDAC), 7.2o, 7.28 and Cultural Organization United Nations Fund for Population Activities UNFDAC, see United Nations Fund for Drug Abuse (UNFPA), 3.Io, 3.I2, 3.29, 6.3, 6.8, 6.I9, 6.27, Control 6.!03, I5.II4 UNFPA, see United Nations Fund for Population United Nations High Commissioner for Refugees, Activities Office of the (UNHCR), 3.50, 3.52, I4.23 UNHCR, see United Nations High Commissioner for United Nations Industrial Development Organization Refugees (UNIDO), 5.8I, 8.17, II.43 UNICEF, see United Nations Children's Fund United Nations Scientific Committee on the Effects of UNIDO, see United Nations Industrial Development Atomic Radiation (UNSCEAR), I r. 37 Organisation United Nations system, see Coordination with the United Union of Soviet Socialist Republics, 6.22, 7.30, 9.31, Nations system 9·II3, 9.22, I0.87 United Nations volunteers, 3·27-3.28 United Arab Emirates, 9.25, 9.28, II.7 United Nations Water Conference (I977), 1.5, 3·4 United Republic of Cameroon, 6.99, 9.62, ro.9 United Kingdom of Great Britain and Northenr Ireland, United Republic of Tanzania, 3·45, 3·55, 5.68, 7·49, 3.II, 7•4, 7·I5, 7.38, 8.30, 9•9, 9•52, 9·!74, 9.I2I, 9·44, 9·5I, 9.53, 9·75, 9.83, 9.180, 9.I86, ro.9, !0.58 10.28, 15.10 United Nations, General Assembly resolution on health United States Agency for International Development as an integral part of development, 3·5 United Nations Advisory Committee on Science and (USAID), 2.I6, 9·37, I5.Io Umted States of America, 2.50, 3.1I, 3.50, 5.38, 5·77, Technology, 4.ro 7•5, 7•9, 7.11, 7.14, 9•52, 9.86, 9.101, 9·174, 9.212, United Nations Children's Fund (UNICEF), 3.ro, 10.4, 1o.p, Io.58, 10.86, 1o.Io5, 12.39, 13.31 3·16-3.18, 3·50, 6.29 Universal Postal Union, 9.8 joint activities, communicable diseases, 9.207, 9.2ro UNSCEAR, see United Nations Scientific Committee diarrhoeal diseases, 9· I42 on the Effects of Atomic Radiation family health, 3.I6, 6.3, 6.5 Upper Volta, 9.51, 9.52, 9·53, 9·174, 9.I82, 9.183 health services, development and evaluation, 2.I6, Urbanization and industrialization, I I.4I, I 5·43, I 5.89 I 5.62 USAID, see United States Agency for International manpower development, I2.83 Development mental health, 7·9 nutrition, 6.6 primary health care, 3.I2, 3.I6, 5·9· 5.I2, 5.22, 6.46, Vaccination, see Immunization, and rmder individual I 3•5 8 diseases water supply and sanitation, II.22, II.23 Vaccination certificates, 9· 5 United Nations Commission on Narcotic Drugs, 7.26 Vaccines, production and quality control, 1.24, 8.29- United Nations Conference on Science and Technology 8.3 7, 9.209-9.210 for Development (I979), 3.4, 4.I0-4.I I projection of requirements, 9.207 United Nations Conference on Technical Cooperation training, 8.29, 8.30, 8.37, I2.II3 among Developing Countries (I978), 3·32 regional and local production, 8.37, 9.129 United Nations Conference on Trade and Development research, 4.I1, 8.31, 8.37, IO.I08 (UNCTAD), 8.17 Variola virus, survey of laboratory stocks, 9· I 5 United Nations Development Programme (UNDP), Vasectomy, 6.97 3•!0, 3·I2, 3•19·3·23, 3•27, 3•30, 5.68, 7·9> 8.4, 8.17, Vector biology and control, 4·37, 5.I6, 9·51, 9·55-9·56, 8.29, 9.40, 9.66, 9·I43, 9.2I0, 9.2I2, I I.6, I 1.24, 9.61, 9.I25, 9·172-9.201, I5.85 II.30, II.44, I5.ro, I5.38, I5.88, I5.89, I5.II3, biological control, 9.192-9.194, 9.231 I5.I20, I5.I27, I5.I31 genetic control, 9·I95 role of resident representatives, 3.22, I I.I9 research units, 9.I84, 9.192 United Nations Disaster Relief Coordinator, Office training, 9.172, 9·199-9.20I, I2.rr5, I2.I35 of the (UNDRO), 3.38, 3·44, 3·49, 5-37, II.37 Venereal diseases, see Sexually transmitted diseases THE WORK OF WHO, 1978--1979

Venezuela, 4oi9, 7050, 9048, 9068, 9o75 migrant workers, 5o69 Veterinary public health, 9o151-9•171, I5o83 research, 4037, 5068 integration in primary health care, 9oi6o World Bank, 3oio, 9059, 9oi43. II.I5 research, I 5o 8 3 cooperative programme with WHO, I r.25-IIo27, training, 9oi52, 9oi6I-9oi63, I2oii3, I2.II4, I5o83 I5 088 VietNam, 3o5o, 8038, 8046, 9oi28, I4o23 World Conference on Agrarian Reform and Rural Village health workers, I2o89 Development (I979), 3o4 Virology, comparative, 9oi68, 9oi69 World Conference on Smoking and Health, Fourth Virus diseases, 9.112-9.139, 9o I 59 (I979). I0o5 5 research, IDo9, IOo26-Ioo29 World Council of Churches, I 3o 58 training in control, 9o I I 9 World Council for Welfare of the Blind, 90148 WHO reporting system, 9oi38-9oi39 World directory of medical schools, I2o63 Virus-associated cancers, IOo9. IOo26-IOo29 World Federation for Medical Education, I2oi9, l2o74 Vitamin A deficiency, 6o4I, 6o42 World Food Programme, 3oi2, 3.24-3.26 Volta River basin area, onchocerciasis control pro­ World Health, 6031 gramme, 9·54-9o6I, I5oi6 World Health Assembly, Io2, 1.3, Io4, Ioi9, Io2I, 1.22, financing, 9o 59-9o6o 1.23, 1.24, 1.27, 1.28, 1.29, 1.30, 1.31 Voluntary Fund for Health Promotion, 3o9, 7oi4, 9oi50 technical discussions, I.I2-Ioi4, 8oi World Health Days (I978 and I979), I.I9, 6031, IDo49, Wastes disposal, 5o I6, I r. 7, I 1.29 I3·59 management of solid wastes, I 1.23, I 5o42 selection of theme for I98o, 1.22, IOo56 Water pollution, IIo4I, II.42, I5o43 World health forum, I3o34-I3o35 see also Coastal pollution World health situation, sixth report, I3o25 Water quality control, 5oi6, II.29, Ir.3o, II.34. rr.38, World Health Statistics Annuals, I3o26 I2ol20, I5o89, I5oi77 World Health Statistics Quarterly, I3o26 Water resources and river basin development projects, World Meteorological Organization (WMO), I5 089 health aspects, 9o39-9o40, 9o43. 9o48, 9oi96 World Rehabilitation Fund, 5o25, I2oi27 see also Volta River basin area, onchocerciasis control programme X-ray equipment, IOo78, IOo8o Water supplies, 1.5, 3oi6, 3052, IIo8, II.14-II.30, maintenance and repair, I5o83 I2oi2I, I5o40, I5ol76 training of X-ray technicians, IOo8o, I2oii8, 12.I34 information transfer, IIo28, II.29 Xerophthalmia, 6042, 9o I49 integration programmes in primary health care, I 1.22, I 1.23, I 1.27 Water-associated diseases, 4o31 Yaws, 9oiio Weaning foods, 606, 6o35 Yellow fever, 3o48, 9oi25, I5oi5, I5o38 Western Pacific Region, 3o53, 4o36-4o38, 5oi2, 5o30, 5°32, vector biology and control, 90178 5o34, 5o40, 5°63, 5o75, 6°24, 6°54, 7o9, 7o54, 8oii, Yemen, 3o27, 5o75. 8044, 9025, 9028, 9075, IOo8 9o29, 9o85, 9o97. 9o20I, IOoi5, II.23, II.44. I2oi9, Youth and adolescence, 6028,6047, I5oll2-I5oll3, I5oi62 I2o20, I2o46, I2o52, I2o62, I2o67, I2o8I, I2oi07, health education, 6o47 15.153-15.184 maturation and reproductive health, 6o23-6o24 Whitepox, 9oi7 mental health, 6023, 7o9 "WHO Action", 3oi3 Yugoslavia, 3051, 9o31 WHO Chronicle, I2ol2, I3o38 WHO representatives, 3022 Zaire, 9oi7, 9oi8, 9063, 9o64 organizational study, 1.9 Zambia, 3o45. 3o48, 5o7I, 7oi5, 7o49, 9o32, 9o2I5, 9o232 see also National coordinators Zoonoses, 4022, 9·151-9·155, 9oi6I-9oi63, I5o52-I5o53 WMO, see World Meteorological Organization centres, 9oi52-9oi5 4 Women in health and development, 304, 606, 609, I5oll2 Mediterranean, 3oi9, 9oi53 Word-processing equipment, 2o6o Pan American, 4022, 9oi52, 9oi63, I2oii3, I5o53 Working populations, health of, 5o67-5.81, I5oi6o research, 9 oI 5 2 agricultural workers, 5068 training, 9oi6I-9oi63, I2oii4