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WORLD HEALTH FORUM. 1988; 9(2):143-6.This article summarizes the activities and the philosophy of WHO in its effort to improve worldwide health care since its inception some 40 years ago. At the 1st World Health Assembly in 1948 it was pointed out that little could be achieved by medical services unless the existing economic, social and other relations among peoples have been improved. The immediate priorities of the new Organization were more limited: to build up health services in the areas destroyed by the war, and to fignt the spread of the big infectious killer diseases. It took almost 30 years before the WHO really got down to trying to do something about the economic, social and other conditions which lie at the heart of most health problems. The Alma-Ata Declaration in 1978 heralded a new era in health. The concept of primary health care and the global health-for-all strategy to implement it are now rapidly gaining ground. In villages, towns and districts, people are waking up to the fact that they can contribute to their own health destiny. As WHO embarks on its 5th decade, there are grounds for optimism: health is moving in the right direction in spite of major obstacles.
[Vaccination, the right of each child, World Day of Health 1987] Vacunacion: derecho de cada nino, Dia Mundial de la Salud 1987.
BOLETIN DE LA OFICINA SANITARIA PANAMERICANA. 1987 Mar; 102(3):263-80.In the 10 years since the Panamerican Health Organization (PAHO) and the World Health Organization initiated the Extended Immunization Program in the Americas (PAI), coverage has increased from less than 1/3 to over 1/2 of children immunized in their first year against 6 major childhood diseases. Due mainly to the PAI, the incidence of measles, tetanus, and diptheria has been reduced by 1/2, that of whooping cough by 75%, and that of tuberculosis by about 5% annually. About 75% of children are immunized against polio, which has 1/10 as many victims today as 10 years ago. PAHO and several other organizations have targeted 1990 for eradication of polio from the South American continent. Since the PAI was established in 1977, more than 15,000 health workers have been trained, cold chains have been established to preserve vaccines, and more than 250 technicians have been trained to maintain and repair the needed equipment. The cost of the campaign to eradicate polio is estimated at US $ 24 million per year for the entire region--a low total compared to the costs of hospitalization and rehabilitation of the victims in the absence of such a program. The goal of immunizing all the world's children by 1990 proposed by the World Health Assembly in 1977 is achievable, but much remains to be done. The number of children immunized in the largest Third World countries ranges from 20-90% owing in part to national immunization days but also to assumption by local communities of the goal of universal immunization by 1990. All deaths produced by these 6 killer diseases are not registered, but the World Health Organization estimates that measles takes 2.1 million lives annually, neonatal tetanus 800,000, and whooping cough 600,000. Governmental and nongovernmental international organizations have made financial help available to countries needing it for their immunization programs. Most developing countries are expected to achieve the goal of universal immunization by 1990, but the 10 poorst countries of Africa and the Eastern Mediterranean may not be able to do so. At the worldwide level, 41% of the 118 million children who survive their first year have been vaccinated against measles and 46% against tuberculosis. 47% have received the full course of vaccine against diptheria, whooping cough, tetanus, and polio. The cost of these immunization is $5-15 per child and 80% is assumed by local countries. The World Health Organization recommends that all children, even the undernourished or slightly ill, be vaccinated, and that all health services vaccinate. Parents should be urged to return for the 2nd and 3rd doses of polio and DPT vaccines. Vaccination programs should pay more attention to impoverished urban populations. Several countries of the region have added innovations such as vaccination against other illnesses, house to house searches for unvaccinated children, or use of mass media to publicize national vaccination programs.
[The Expanded Programme on Immunization: the results of its realization, problems and prospects] Rashirennaia Programma Immunizatsii: resultaty osushchestvleniia, problemy i perspektivy.
ZHURNAL MIKROBIOLOGII, EPIDEMIOLOGII I IMMUNOBIOLOGII. 1985 Feb; (2):114-20.A report to interested physicians in the USSR explained the progress of and problems associated with the World Health Organization (WHO) expanded immunization program, set up by resolution in 1974, to inoculate every child in the world up to age 1 against measles, pertussis, tetanus, polio, diphtheria, and tuberculosis by 1990. The program called for distribution of DTP anatoxin, live polio and measles virus, and Calmette-Guerin bacillus. By 1983, 50% of children in Europe, America, the Peoples Republic of China, and the immediately contiguous areas had been vaccinated against polio and DTP, but in developing countries the figures were only 24% and 31% respectively, and only 26% and 14% for measles and tuberculosis respectively. The decision was made in 1983 to concentrate more effort and resources on establishing national health programs by training higher level administrative workers and technicians to work at the local level in storing and delivering vaccines, and operation and maintenance of the refrigeration equipment, which is of vital importance in tropical regions. Refrigeration equipment has been developed recently to meet the unique conditions of the developing nations, periodic comprehensive evaluation of program implementation is conducted, and a series of laboratory and field studies are now underway to improve efficiency of implementation by improving the thermal stability of vaccines and the refrigeration chain, increasing availability of vaccines to the population, and improving the economy of operations. Audits show that vaccine losses now account for only 14% of expenditures, with 45% going for labor. Almost 80% of all costs are now being met by the countries involved. Thus, international cooperation has been instrumental in the results of the expanded immunization program.
Grass roots, herbs, promoters and preventions: a reevaluation of contemporary international health care planning. The Bolivian case.
Social Science and Medicine. 1983; 17(17):1281-9.In evaluating a United States Agency for International Development (USAID) project in Bolivia, the author argues that the program unwittingly contributed to the situation that created Bolivia's political problems. A 5-year pilot project which covered 39 villages and colonies in the Montero district in the state of Santa Cruz began in 1975 and was completed in 1980. In 1980 the project was "deobligated" when all but essential economic aid to Bolivia was halted following a political coup. The pilot project was based on 1) community participation through health care; 2) a referral system from health post of the promotor to the center with an auxiliary nurse midwife, to secondary and tertiary care in hospitals by physicians; 3) an emphasis on preventive medicine; and 4) the use of traditional medicine along with other therapy by the promotor. Although these concepts sound appropriate, they are in fact derived from contemporary thought in advanced industrial societies. The assumptions about social reality that are inherent in these plans actually misconstrue Bolivian society. The unintended consequences of the project actually diminish rural health care. A difference between the Western health planner's conception and the Bolivian conception--of community, of effective referral systems, of preventive and indigenous medicines--can have the effect of producing a health care program that has little resemblance to what was originally intended. The Bolivian elite actually manipulated the USAID health care programs through hegemony in the villages. The Jeffersonian concept of community is not applicable in Bolivia where resources are only exchanged through personal contacts. In villages of multiple class or ethnic groups or both or in villages with close ties or histories of ties with larger, more cosmopolitan groups, multiple different interests exist. These work against each other to prevent the very cooperation envisioned by the health care programs. The author suggests that developed countries should consider native ideologies, native social relations, and indigenous medicine more sensitively in design.
REVIEWS OF INFECTIOUS DISEASES. 1983 May-Jun; 5(3):452-9.This summary of the worldwide impact of measles discusses epidemiology, reported incidence, clinical severity, community attitudes toward measles, and the impact of immunization programs on measles. Measles, 1 of the most ubiquitous and persistent of human viruses, occurs regularly everywhere in the world except in very remote and isolated areas. Strains of measles virus from different counties are indistinguishable, and serum antibodies from diverse population have identical specificity. Yet, the epidemic pattern, average age at infection, and mortality vary considerably from 1 area to another and provide a contrasting picture between the developing and the developed countries. In the populous areas of the world, measles causes epidemics every 2-5 years, but in the rapidly expanding urban conglomerations in the developing world, the continuous immigration from the rural population provides a constant influx of susceptible individuals and, in turn, a sustained occurrence of measles and unclear epidemic curves. In the economically advanced nations, measles epidemics are closely tied to the school year, building up to a peak in the late spring and ceasing abruptly after the summer recess begins. Maternal antibody usually confers protection against measles to infants during the 1st few months of life. The total number of cases of measles reported to WHO for 1980 is 2.9 million. Considering that in the developing world alone almost 100 million infants are born yearly, that less than 20% of them are immunized against measles, and that various studies indicate that almost all nonimmunized children get measles, less than 3 million cases of measles in 1980 is a gross underestimate. There was adecrease in the global number of reported cases of measles during the 1979-80 period due primarily to the reduction in the number of cases in the African continent and, to a lesser extent, in Europe. It is premature to conclude that such a reported decline is real and that it reflects the beginning of a longterm trend. The contrast between the developed and the developing worlds is most marked in relation to the severity and outcome of measles. Case fatality rates of more than 20% have been reported from West Africa. It has been estimated that 900,000 deaths occur yearly in the developing world because of measles, but data available to WHO indicate that the global case fatality rate in the developing world approaches 2% (in contrast to 2/10,000 cases in the US), and the actal mortality may be greater than 1.5 million deaths per year. The advent of WHO's Expanded Program on Immunization has brought about an awareness of the measles problem. Whenever and wherever measles vaccine has been used effectively on a large scale, a marked reduction in the number of cases has been recorded.