many countries are anxious to determine the extent of their tuberculosis problem so as to establish what is termed a base line. On its basis, they propose to plan effective programs adapted to their own circumstances, and based on drug treatment in patients' own homes.

These changes have modified the policy of WHO. Instead of the uniform approach of establishing demonstration centers, the work has now been directed to the creation of satisfactory techniques for surveys and control programs of tuberculosis. To this end, pilot projects in India, Tunisia, and elsewhere are being organized to discover the effect of home treatment by drugs on the individual and, even more, on the spread of the disease among communities.

Treponematoses

The fact that diseases like yaws, pinta, and bejel respond favorably and rapidly to penicillin treatment, has made possible extensive mass campaigns against yaws in many countries in Asia, Africa, and South America.

The object of these campaigns is to discover as many active and latent cases as possible and to treat them and their contacts with penicillin. This involves the training of national staff in modern diagnostic, therapeutic, and epidemiological methods. Specialized services are required in the early stages of mass campaigns to reduce the prevalence of these diseases to a level at which the growing rural health services can take over and maintain surveillance and control.

F. OPERATING PROGRAMS-STRENGTHENING NATIONAL HEALTH SERVICES

Campaigns to control or eradicate specific diseases must supplement and not substitute for the enduring national structures for the protection of public health. As was pointed out above in relation to communicable disease control programs, it is most important that the specialized programs be operated in relation to and eventually as a part of national public health organizations. But if this is to come about, there must be a national public health structure capable of carrying on a broad spectrum of health protection activities month by month and year by year.

Many nations need help in strengthening their own health services. WHO is prepared to lend assistance in this task upon requests from national governments.

Relationship to overall technical assistance

In providing assistance, the dependence of all health measures upon general economic and social development is recognized by WHO. So, too, it perceives the long-run dependence of specific disease control measures upon sound national health structure. WHO alone could never hope to solve the overall problems of underdeveloped countrieseven those of health-unless it pursued its efforts in a concerted program of technical assistance designed to bring about a comprehensive strategy against disease, poverty, and ignorance. It is only through such a program that standards of living can be significantly improved, and the well-being of hitherto underprivileged communities permanently insured.

Rural health units

Efforts to strengthen national health services require that attention be paid to a number of specialized activities, such as protection of maternal and child health, health education, nutritional problems, and environmental sanitation. But attention must also be paid to the way in which these specialties are knitted together and made available in a way that makes sense to the people whom they are supposed to aid.

In connection with the problem of making a whole out of parts, it is fortunate that assistance in the establishment of decentralized and integrated services in rural districts through rural health units is becoming an increasingly popular request from governments. The object of these rural health units is to demonstrate through studies and trials, the least costly and the most efficient way in which national health departments could progressively extend from urban to rural areas. In such a process much responsibility for the health work required devolves on auxiliary personnel and indeed on the villagers themselves. The training of paramedical staff and auxiliaries is therefore an essential part of this work.

Against this general background of means of improving health services, some important specialties in health protection may now be examined.

Maternal and child health

The health development of the child is an important long-term investment for the future well-being and welfare of nations. Maternal and child health programs deservedly have not only a strong emotional and humanitarian appeal but they are also fundamental to an enlightened program.

The early type of joint UNICEF-WHO maternal and child health project aimed at setting up a demonstration center in which international experts trained their counterparts in the techniques of antenatal, natal, and postnatal care of mothers, and the care of infants, and in the management of "well baby" clinics. This concept has gradually been amplified to meet existing needs and possibilities. Today, maternal and child health work is often combined with programs of environmental sanitation and communicable disease control, particularly within community development projects in rural areas. Specialized aspects of the Organization's maternal and child health program include the care of premature infants, assistance to rehabilitation programs for handicapped children, and the organization of school health services.

Health education

If public health measures are to be successful, the people as a whole must understand them, take an interest in them, and actively participate. In projects designed to promote health or to prevent disease no less than in those for medical care, education of the public is an essential constituent. Because it has taken account of the needs and of the social and cultural conditions of the people, preference has been given to the training of local staff in this technology rather than to the assignment of foreign experts to work among communities totally unknown to them.

Nutrition

Nutritional studies and projects, often supported by EPTA (expanded program of technical assistance) funds and by UNICEF, are undertaken by the Organization in collaboration with the Food and Agriculture Organization. Nutrition surveys, nutrition institutes, and similar projects often require the facilities of both Organizations. In maternal and child health projects and in school health service projects, UNICEF plays an important part in providing milk and vitamins for expectant or nursing mothers, for infants, and for improving the general fitness of schoolchildren.

Environmental sanitation

Environmental sanitation is an essential part of any health program. Unfortunately there is a worldwide acute shortage of sanitary engineers. The World Health Organization is doing its utmost to encourage their training.

A series of technical publications has been made available to governments. Frequent regional seminars on the hygiene of public water supply, sewerage, solid waste disposal, food and milk hygiene, and on similar topics are organized.

Sanitary engineers are appointed to field projects on health demonstration teams. Their task varies from organizing environmental sanitation sections in the ministries of health to building wells and latrines adapted to local resources and nature of terrain. Sometimes their task is even more complex-like the improvement of irrigation systems for the elimination of the snail vector of bilharziasis.

G. EDUCATION AND TRAINING

The three principal aims of education and training are to help countries to meet their shortage of personnel; to provide teaching and demonstration teams to promote technical skill and knowledge; and to assist in the exchange of scientific information.

These three aspects of education and training have acquired a high priority in WHO services because of the acute shortage of medical, nursing and other professional personnel in practically all the developing countries and the urgent need for training auxiliary health workers to tide over the shortage of fully qualified workers.

The significance of education and training is such that this aspect of WHO's activities is discussed in greater detail in the following part.

H. TRENDS

Ten years is a relatively short period for identifying general trends in the work of a body such as WHO. But certain trends are clear.

There is no doubt about one trend-the amount of work, occasioned by increased demands. As measured by such indexes as the size of the budget and the number of staff, work has almost trebled during the decade. The small number of country projects in the few "priorities" of the First World Health Assembly in 1948 contrasts with the hundreds in 1957 in a wide range of health and medicinal subjects. The character of the projects has been changing. In general, action to meet emergencies and projects designed to meet limited needs are giving place to programs, planned in advance for a period of years. Thus, the single service of limited scope has been increasingly replaced

by the comprehensive project that assists a country to organize, for example, a mass campaign against a communicable disease, or provides a visiting team of medical teachers. Projects have also been more fully planned and more carefully controlled.

A normal sequence is now:-the initial survey, the associated epidemiological review, the operation of the project and the final analysis of work done. Regional work has also been broadened by the more frequent requests in recent years for intercountry projects, demonstrations, or seminars.

There has been a significant and natural trend in the educational and teaching programs. The early single fellowship is now often replaced by a system of fellowships provided as part of a whole country program. Visits by full teaching faculties, as well as by_single teachers, are now used to assist local education programs. Educational meetings are more prominent in number and variety. Seminars, study groups, and conferences, as well as group training programs such as courses, have become a feature of most technical programs in recent years. Coordinated programs in which several national and international agencies cooperate have become more important.

Meanwhile, research has evolved from an activity arising directly out of communicable disease control programs to an activity concerned with investigations related to chronic diseases and to the basic phenomena underlying the physical and mental health of human beings.

Part III

THREE ILLUSTRATIVE WHO PROGRAMS ANTI-INFLUENZA, ANTI-MALARIA, AND TRAINING ACTIVITIES

In describing the total objectives and various programs of WHO, as was done in part II, the range of activities to be covered is so broad that each must be dealt with briefly.

This brevity may lead to abstraction and to the omission of the type of details which convey a sense of reality and urgency. In this present part, therefore, certain WHO activities relevant in different ways to the United States are described in some detail so that the nature of the programs may be seen more clearly.

The first is about the operation of an early warning network for worldwide communicable diseases, taking influenza as an example and the 1957 world epidemic as the center of discussion.

Second is described a program for eradication of a major disease of interest to the United States because of humanitarian considerations and because of the worldwide economic effects if eradication is successful. The example chosen is malaria.

Third, the efforts of the World Health Organization to mitigate a worldwide shortage of health personnel is described. This is of course very pertinent to our country because any efforts which the United States makes to improve the health of the world will depend heavily upon expanding the amount of technical competence in the world. Thus this country has a direct interest in the success of the training and educational activities of the WHO.

A. THE WORLDWIDE INFLUENZA EPIDEMIC OF 1957

1. INTRODUCTION

The worldwide influenza epidemic of 1957 was a needed reminder of the manner in which a communicable disease can spread around the world in a matter of months. The disease spread from inland China in both directions around the world to attack the United States almost simultaneously on both coasts and inland. No more solid. proof of the continuing susceptibility of this country to epidemic from other countries could exist.

From discussions with scientists and public health experts both in the United States and in Europe, and particularly with officials of the World Health Organization, supplemented by a review of available reports, the story of the epidemic can be reconstructed. Special attention will be devoted to the implications of the episode to the health of the population of the United States in the future.

47