86th Congress 151; Session COMMITTEE PRINT .7 THE’UNITED STATES AND THE WORLD HEALTH ORGANIZATION ' TEAMWORK FOR MANKIND’S WELL-BEING REPORT OF SENATOR HUBERT H. HUMPHREY BASED ON CONFERENCES IN EUROPE IN.NOVEMBER AND DECEMBER 1958, AND ON SUBSEQUENT REVIEW PRECEDING THE 12TH WORLD HEALTH ASSEMBLY, » MAY 1959 . PREPARED FOR THE ‘ COMMITTEE ON GOVERNMENT OPERATIONS * UNITED STATES SENATE AND ITS SUBCOMMITTEE ON REORGA‘NIZATION AND INTERNATIONAL ORGANIZATIONS (PURSUANT TO S. RES. 347, 85TH CONGRESS, AND S. RES. 42, 86TH CONGRESS) MAY 11, 1959 Lzaaem UNNERSH‘Y Printed for the use of the Committee on Gwenifr’fe’fit Operations UNITED STATES GOVERNMENT PRINTING OFFICE 38516 WASHINGTON : 1959 oc.x1 For sale by the Superintendent of Documents, US. Government Printing Ofliee Washington 26, DC. - Price 50 cents := GALl'r’ORNli -_ 31312.12 .1231! 21.21;. COMMITTEE ON GOVERNMENT OPERATIONS JOHN L. McOLELLAN, Arkansas, Chairman HENRY M. JACKSON, Washington KARL E. MUNDT, South Dakota SAM J. ERVIN, J 12., North Carolina CARL T. CURTIS, Nebraska HUBERT H. HUMPHREY, Minnesota HOMER E. CAPEHART, Indiana ERNEST GRUENING, Alaska EDMUND S. MUSKIE, Maine WALTER L. REYNOLDS, Chief Clerk and Stafl‘ Director SUBCOMMITTEE 0N REORGANIZATION AND INTERNATIONAL ORGANIZATIONS HUBERT H. HUMPHREY, Minnesota, Chairman JOHN L. McCLELLAN, Arkansas HOMER E. CAPEHART, Indiana ERNEST GRUENING, Alaska KARL E. MUNDT, South Dakota EDMUND S. MUSKIE, Maine Jvuus N. Cum, Director of Medical Research Project II My W7 ‘ g L 1" ' J o , HEALTH 4 ‘ . ‘ ’ ' 1.189.: v LETTER OF TRANSMITTAL .« US. SENATE, May 11, 1959. Hon. JOHN L. MCCLELLAN, Chairman, Senate Committee on Government Operations, Senate Ofiice Building, Washington, DC. MY DEAR MR. CHAIRMAN: There is attached for your considera- tion a committee print entitled, “The United States and the World Health Organization.” It is based in part on conferences held in Europe in the course of my trip in November and December 1958. This was in my capacity as chairman of this subcommittee in its conduct of the international health study authorized by the Senate. Upon my return to the United States, I made a further review of phases for which sufficient time had not been available during the tour. The combined data is presented herein. It is intended as an ex- pression solely of my personal views since, unfortunately, the heavy schedule of other subcommittee members did notvpermit them to accompany me on the trip. This print is the fourth in a series of publications issued by this subcommittee for purposes of background to our overall mission. Earlier prints were entitled: 1. “International Medical Research.” £537 {{5 2. “Statutory Medical and Health-Related Research in the (8'5“ United States Government—The Basis for International Coop- Q , eration.” 5 43¢ 3. “The Status of World Health—In Outline Text and Chart.”/e,; 9, 7 Each of these three publications were intended for factual and £43377 information purposes only. The present print, however, offers substantive findings. These observations are personal, as noted above, and necessarily tentative. Additional data will be compiled and analysis made in the period prior to the final report of the subcommittee on January 31, 1960. Other publications, designed to illuminate the broad spectrum of world health problems and responses are now in the process of preparation. With kindest wishes, I am, Sincerely yours, HUBERT H. HUMPHREY, Chairman, Subcommittee on Reorganization and International Organizations. III 068 .———— 7*“ CONTENTS Page Letter of transmittal ________________________________________________ In Introductory section _______________________________________________ 1 . The background of Senator Humphrey’s 1958 trip to Europe____ 1 B. The plan of this print _______________________________________ 6 C. Summary of 10 principal findings _____________________________ GD PART I. WORLD HEALTH—STATUS AND RESOURCES A. The challenge __________________________________________________ 63 B. The response—Past successes ____________________________________ 4 C. World resources for health _______________________________________ PART II. EVOLUTION OF WHO ACTIVITIES A. The constitutional base __________________________________________ 37 B. First objective—Create a world framework for health _______________ - C. Second objective—Strengthen national health structures _____________ D. Evolution of functions-______-________-____-___;- ________________ 40 E. Operating programs—Communicable diseases ______________________ Malaria ___________________________________________________ Tuberculosis control- _ _ _ _ _ - _' ________________________________ 4 Treponematoses ____________________________________________ 3 F. Operating programs—Strengthening national health services _________ 43 Relationship to overall technical assistance ____________________ 43 Rural health units __________________________________________ 44 Maternal and child health ___________________________________ 44 Health education ___________________________________________ ' 44 Nutrition __________________________________________________ 45 Environmental sanitation ____________________________________ 45 G. Education and training __________________________________________ 45 H. Trends ________________________________________________________ 45 PART III. THREE ILLUSTRATIVE WHO PROGRAms—ANTI-INFLUENZA, ANTI- MALARIA, AND TRAINING ACTIVITIES A. The worldwide influenza epidemic of 1957 _________________________ 47 1. Introduction ____________________________________________ 47 2. History of the epidemic ___________________________________ 48 Introduction of the virus ______________________________ 49 Virus “seeding” ______________________________________ 49 The main epidemic phase _____________________________ 49 The postepidemic phase _______________________________ 50 3. The WHO influenza program ______________________________ 50 4. Interrelationships of research and disease control ___________ 52 B. Malaria eradication _____________________________________________ 53 1. The two technical advances _______________________________ 54 2. Early strategic decisions __________________________________ 54 3. Operational procedures- _ _ _ - - - - - _' _________________________ 54 4. A revolutionary development ______________________________ 55 5. Meaning Of malaria eradication ____________________________ 55 6. Insect resistance _________________________________________ 56 7. Response—Eradication- _ _ _ '_ ______________________________ 56 8. The research response ____________________________________ 57 (a) Laboratory research ______________________________ 58 (b) Field research ____________________________________ 59 9. Impressive results ________________________________________ 59 V VI CONTENTS Page C. Education and training-_____-_-_- _ _ _-. __________________________ 61 1. Provide technical skill by fellowships ______________________ ("f - 62 2. Provide technical skill by exchange _________________________ ‘ 65 3. Collect, analyze, and distribute information _________________ 66 PART IV. DEVELOPMENT or WHO’s MEDICAL RESEARCH A. Constitutional base _______________________________________ 1 ..... 68 B. Early program priorities _________________________________________ 68 C. The research center approach ____________________________________ 69 D. Infectious diseases ______________________________________________ 71 1. Tuberculosis ____________________________________________ 71 2. Trachoma _______________________________________________ 71 3. Yaws and syphilis ________________________________________ 72 E. N oninfectious diseases and special problems _______________________ 73 1. Nutritional research____-___________________-_______.- _____ 73 2. Drug addiction __________________________________________ 75 3. Pharmaceutical preparations and biological standardization- _ - 76 4. Chronic diseases of major significance in the United States---_ 77 (a) Cancer __________________________________________ 77 (b) Cardiovascular ailments ___________________________ 77 (F3 The future of international medical research and WHO ______________ 79 PART V. THE INTANGIBLE ASSETS or WHO A. Cooperation from individuals ____________________________________ 83 1. WHO research planning conferences ________________________ 83 2. Expert advisory panels ___________________________________ 85 3. American delegates to health assemblies ____________________ 87 Laboratories cooperating with WHO ______________________________ 93 Coordination with U.N. organizations _____________________________ 96 1. Economic and Social Council _____________________________ 96 2. The United Nations Children’s Fund _____--_' _____________ 98 3. Food and Agriculture Organization ________________________ 100 4. United Nations Educational, Scientific and Cultural Organiza- 101 tion _________________________________________________ 5. International Labor Organization _________________________ 101 6. United Nations Relief and Works Agency __________________ 101 7. U.N. Department of Economic and Social Affairs ___________ 102 8. U.N. narcotics control ___________________________________ 102 9. The need for constant review of jurisdictional lines __________ 102 10. Cooperation on radiation problems ________________________ 103 D. Cooperation with international professional organizations ____________ 104 E. WHO and US. Groups __________________________________________ 109 1. Relationships with pharmaceutical organizations _____________ 109 2. Relationships with the academic world ______________________ 111 3. Relationship with foundations and associations ______________ 112 F. Relationships with the U.S.S.R. and countries of Eastern Europe _____ 113 G. The proposed international public health and medical research year--- 115 H. The highest asset—Moral purpose ________________________________ 118 PART VI. WHO’s MATERIAL REsouncas A. WHO’s total resources __________________________________________ 121 1. Total finances ___________________________________________ 121 2. Regular budget __________________________________________ 125 3. Malaria eradication s cial account ________________________ 127 4. Expanded program 0 technical assistance ___________________ 127 B. General expenditure patterns ..................................... 128 Rising operating programs ________________________________ 129 2. Declining share absorbed by administration _________________ 129 C. Financial audit _________________________________________________ 129 D. The substance of field work ______________________________________ 130 E. WHO’s malaria eradication program ______________________________ 131 F. WHO staff _____________________________________________________ 134 G. Future financial needs and programs ______________________________ 140 H. Conclusion ..................................................... 144 H 1 tb ITTTTTTT >ow>mowmuow 03¢wa 6—F 6-G an a3 eK 6—L 6—M 6—N CONTENTS ~ Lrs'r or CHARTS Proportion of deaths from tuberculosis and other infectious diseases in total number of deaths: 1920 and 1956 _____________________ Notifications of cases of smallpox ______________________________ Smallpox—Total of officially notified cases by continents __________ Notifications of cases of cholera, 1948 and 1957 __________________ Plague: Reported cases—1957 _________________________________ Regression of typhus _________________________________________ Expectation of life at birth ____________________________________ Death rates—Infant death rates 1920 and 1956 __________________ Progress of influenza epidemic from February 1957 to January 1958- _ World influenza centers as at March 1958 _______________________ Status of malaria eradication in the world at the end of 1957 ______ WHO polio centers as at April 1958 ___________ ‘ _________________ Amounts authorized for use by WHO, 1953—59 __________________ Revised estimates under regular budget for 1957 compared With approved 1958 and 1959 estimates ___________________________ Approved use of 1958 budget, by percentages ____________________ Distribution of stafl" by work location ___________________________ Distribution of professional staff by nationality __________________ LIST OF TABLES Infectious disease problems, by continent _______________________ Number of physicians, by continent ____________________________ U.S. delegations to International Health Conferences and World Health Assemblies—lst through 12th ________________________ Institutions and laboratories closely associated with WHO ________ Nongovernmental organizations in official relationship with WHO- Distribution of contributions to the 1959 regular budget of WHO..- Obligations incurred 1952 to 1957 and estimated costs for 1958 and ' 1959 under the regular budget, the malaria eradication special account, the expanded program of technical assistance, and UNICEF reimbursements __________________________________ Contributions to the 1959 regular budget of WHO by country____ Approved budgets of the Pan-American Health Organization and the special malaria fund, and funds obligated in the region of the Americas from WHO for the years 1952—57, with estimated costs, 1958 and 1959 _____________________________________________ Breakdown of obligations by major purposes, 1952—57, and estimated costs for 1958 and 1959 under the regular budget, malaria eradica- tion special account, expanded program of technical assistance, and UNICEF reimbursements _______________________________ Obligations in respect of projects by specific fields of activity, 1952— 1957, under the regular budget, expanded program of technical assistance, and UNICEF reimbursements ____________________ Estimated government contribution to malaria eradication programs in their countries for the years 1958, 1959, and 1960, with esti- mated costs to WHO (all funds) _____________________________ Malaria eradication special account ____________________________ Total WHO stafl", by function, 1957—59 _________________________ Summary by purpose-of-expenditure code, indicating percentages of total regular budget estimates _______________________________ World Health Organization—Geographical distribution of staff, 1950-58 __________________________________________________ US. and Soviet contributions to the World Health Organization__ Contributions to special projects of the World Health Organization by the United States and Soviet Union _______________________ United Nations expanded program of technical assistance funds obli— gated by the World Health Organization _____________________ 127 128 1m iw % m4 m5 136 143 m4 M4 INTRODUCTORY SECTION A. THE BACKGROUND OF SENATOR HUMPHREY’S 1958 TRIP TO EUROiPE On August 18, 1958, the US. Senate unanimously approved Senate Resolution 347, 85th Congress. The Committee on Government Oper- ations was directed thereby “to make a full and complete study of any and all matters pertaining to international health, research, rehabilita- tion, and assistance programs.” By the decision of the chairman of the committee, the Honorable John L. McClellan, responsibility for the study was entrusted to the standing Subcommittee on Reorganization and International Organi- zations. This subcommittee is res onsible, among other duties, for— (a) Analysis of legis ation and of administrative problems re- lating to the organization of the Federal Government. (b) Review of American relations with international organiza- tions. In both of these respects, the international health study comes clearly within the purview of the subcommittee. By way of illus- tration— (a) Health research engages the attention of over a half dozen agencies of the Federal Government. (b) Health activities fall, as well, Within the scope of numerous intergovernmental organizations of which the United States is a member. Outstanding among such organizations is the World Health Organization. Related intergovernmental organizations in which the United States participates are the United Natidns , Children’s Fund, the Food and Agriculture Organization, the International Labor Organization (the last named with particular reference to occupational health) and the United Nations Educa— tional, Scientific, and Cultural Organization. To analyze both of these phases, a comprehensive work plan was prepared. Questionnaires were sent out, reports were requested, interviews and conferences held. ‘ Specific purposes in tour of European Health Centers Commencing November 17, 1958, the scene of the inquiry turned from the United States to relationships with foreign governments and with intergovernmental organizations in Europe itself. For several intensive weeks thereafter, I held formal and informal discussions with officials and private individuals in nine European countries: France, Switzerland, West Germany, Denmark, Sweden, Finland, the Soviet Union, Norway, and the United Kingdom, in that order. My purpose was to gain facts and insight on— («1) Problems of world health. (6) The ways in which the US. Government itself is helping to meet these problems. 1 2 UNITED STATES AND WORLD HEALTH ORGANIZATION (c) The ways in which intergovernmental organizations of which the United States is a member are meeting the problems. Or, expressed in another way, I sought understanding of— (a) The health challenge; (6) The US approach to the challenge—unilaterally (through our own independent efl’orts at home), bilaterally (through copiperation in each instance with another individual country); an (a) Multilaterally——through participation in a multination organization. The fact is that, increasingly, there is a blending of all three types of effort—unilateral, bilateral, and multilateral. The conduct of medical research, as such, provides perhaps, the best example of the fusing of these modi operandi. But medical assistance to the developing areas of the globe is likewise increasingly involved in the constructive interplay of bilateral and multilateral relationships. To help determine, then, how the American taxpayer’s money is being spent for research purposes by US. Government health agencies at home, it is invaluable to know what we are doing in our research efforts abroad. The converse is true as well. . Science, especially medical science, is international. This was the theme of the first committee print in the subcommittee’s series of publications. Science, to be fully successful, requires genuine coopera— ation among the nations. Key role of WHO in world health In country after country, as I traveled throughout Europe, I found that one means of cooperation—one organization—emerged in almost every conversation on the topic of health. ‘ That organization is, of course, the World Health Organization. Its three initials—WHO—have become virtually synonymous with efforts in world health. WHO has become the hub of_ the world health wheel, the center of motion for innumerable constructive forces. Wherever I went in Europe I found reference to its good works on the continent and disseminating throughout the world. Geneva, its world headquarters, was of course an ideal location to obtain the central view of its farflung work. But it is not the best place to see its works themselves, as WHO ofiicials readily stated. WHO is a regionalized and decentralized organization, the crux of whose efforts may best be seen in the field, notably in the developing areas of the globe. , Had time been available for my visiting the Middle East, as I had previously, or south Asia, Latin America, or Africa, I am certain that the powerful impact of WHO would have been felt even more keenly than I did feel it in Europe. In instance after instance, while commenting on themes of health cooperation with health officials in, say, Paris, Stockholm, or Moscow, I found that WHO entered almost inevitably into the discussion. Since so many of the conversations gravitated to the theme of WHO, I felt that this report to the committee and to the Congress might serve to best advantage if it concentrated on this remarkable organization. UNITED STATES AND WORLD HEALTH ORGANIZATION 5 3 But WHO can only be understood by viewing the problem of world health itself. That is why, throughout this report, there is a constant dual focus of discussion on— (a) health needs, and (b) health responses. That is why, too, much of this report is necessarily devoted to detailed description, before offering specific evaluation. l , At this stage, the views expressed herein are necessarily not cOm- plete. The study by this subcommittee still has many months before it. Additional insight from correspondence, conferences, and reports is constantly being gained, in preparation for the final report by this subcommittee, scheduled for January 31, 1960. , Nevertheless, it was felt that the time was opportune to set down these tentative notations and to do so, in advance of AmeriCa’s participation in the Twelfth World Health Assembly, composed of representatives of the member countries of WHO which will commence on May 12, 1959. Conferences on other subjects during 1958 trip The pages which follow will refer almost exclusively to world health, as viewed through the lens of an American legislator in con- tact with WHO. , However, subsequent subcommittee publications will contain many references to a» wide variety of observations made in the course of my N ovember—December tour, apart from the subject of WHO. I would be remiss, now, however, if I did not acknowledge the courtesies extended to me during the trip by a broad variety of hosts within and outside Geneva. They included political leaders, health officers, scientists, and physicians among all the nine countries. Nowhere, regrettably, did I find suflicient time to confer in the depth that I had hoped with all these many cordial individuals. Within‘the limitations of time, however, each sought to give me judgment hnd counsel in the field of health. Discussions with health oficials win/Europe The number of individuals were so numerous that the following is but a brief and inadequate listing: - PARIS, FRANCE M. Bernard Chenot, Minister of Health. 1 Prof. Louis Bugnard, Director, National Institute of Hygiene. Prof. Robert Debre, Member Executive Board, United Nations Children’s Fund. Dr. J. F. Delafrasnaye, executive secretary, Council of International Organizations in Medical Sciences. Prof. Georges Schapira and Prof. Jean Claude Dreyfus, Laboratory of Bio- Chemical Medical Research. Prof. Maurice Lamy, Medical Genetics Clinic, Hospitale des Enfants Malades. Dr. Raymond Latarjet, Director, L’Institut de Radium. , Prof. Jacques Trefouel, director, Pasteur Institute (together with Profs. Andre Lwofl‘ and Francois Jacob). ; Dr. A. Minkowski, director, Neo—Natal Research Center, Maternity Hospital. Also included in conferences in Paris at my invitation: Prof. M. W. Woerdeman, chancellor, University of Amsterdam and chairman of the Excerpta Medica Foundation (together with Mr. E. van Tongeren, director of the foundation, both of Amsterdam). 4; UNITED STATES AND WORLD HEALTH ORGANIZATION STOCKHOLM, SWEDEN Rectdr Sten Friberg, Karolinska Institute, together with: Prof. Hugo Theorell, Bio—Chemical Department, Nobel Medical Institute. Prof. T. Casperson, Department of Medical Cell Research and Genetics, Nobel Medical Institute. Prof. B. Malmgren, Bacteriology Department, Karolinska Institute. Also present in Stockholm at my invitation: Prof. Henri Tagnon, Institute Jules Bordet, Brussels. Dr. David Karnovsky, Sloan-Kettering Institute, New York. HELSINKI, FINLAND Prof. A. I. Virtanen, president, Finnish Academy of Sciences. Prof. Eero Vroma, State Serum Institute. Prof. Arvo Ylppo, Children’s Castle. Dr. Eero Hillbom, Research Institute for the Brain-Damaged. Dr. Paavo A. Kuusisto, National Board of Medicine. Prof. Ilamari Vartiainen, dean of medical faculty, University of Helsinki. Dr. M. Karvonen, Institute of‘ Occupational Health. Prof. Nillo Hallman, University Clinic for Children’s Diseases. MOSCOW, SOVIET UNION Prof. Semyon Sarkisov vice chairman, Academy of Medical Sciences. Prof. V. M. Zdhanov, Deputy Minister of Health. Profigicholas Blochin, director, Institute of Experimental Pathology and Therapy of ancer. , Dr. V. N egovsky, Institute of Physical Resuscitation. NORWAY Dr. Leiv Kreyberg, Rikshospitalet. / Dr. Lorentz Eldjarn, Radium Hospital. UNITED KINGDOM Sir Harold Himsworth, United Kingdom Medical Research Council. Meetings with political leaders Cited above are solely leading experts in the field of health. There should be mentioned now the political leaders With whom I had the. honor oi discussing among other subjects, broad policies of health cooperation. They included: Chairman of the Council of Ministers of the U.S.S.R., Nikita S. Khrushchev. Secretary General of the North Atlantic Treaty Organization, Paul Henri Spaak. Prime Minister Tage Erlander of Sweden. President Urho Kekkonen of Finland. Acting Foreign Minister Arne Skaug of Norway. British Foreign Secretary Selwyn Lloyd; in addition to Leader of the Opposition Hugh Gaitskell. Uponmy return to the United States, I reported on medical and nonmedical subjects to President Dwight D. Eisenhower at the White House, as well as to the then Acting Secretary of State, Chris- tian A. Herter. ‘ It was and is my firm conviction that, as a rule, only When the highest echelons of government take a deep and continuing. interest in health problems, can further substantial progress be made. Assistance in compilation of health data _ Finally, I should like to mention, that in connection with this par- tlcular publication, no sin 1e individual deserves more appremation for helpfulness than the istinguished Director General of WHO, Dr. M. G. Candau. UNITED STATES AND WORLD HEALTH ORGANIZATION 5 His ready cooperation commenced from the very first meeting IE1!) October 1958, with the project director of our study, Mr. Julius . Cahn, Whom I had asked to make an initial review of fields of interest to the subcommittee. One month later, on my own arrival in Geneva, I found that Dr. Candau’s efficient staff had prepared many useful reports in response to all of the initial uestions submitted on behalf of our subcommittee; and the WHO staffJl was eager to follow up, as needs required. In the course of my visit, Dr. Candau and his leading associates met for many hours around the conference table with myself and subcommittee staff. Conferees included, among others, Dr. Pierre Dorolle, Deputy- Director General; Assistant Director General for Advisory Services P. M. Kaul; Mr. M. P. Siegel, assistant director-general for adminis- tration and finance; Dr. Martin Kaplan, Chief of Veterinary Health; Dr. Erwin Kohn, Director, Special Oflice for General Medical Re- search Planning; Dr. A. M. M. Payne, Chief of Virus Section, Division of Communicable Disease Services; Dr. L. J. Bruce-Chwatt, with regard to malaria eradication; and others. Questions which came up which required subsequent detailed response were fully covered in reports conveyed thereafter. 1 In Copenhagen, supplementary data were gathered as well from WHO Regional Director for Europe Dr. Paul J. J. van der Calseyde. Before leaving Geneva, I met briefly with David Morse, Director General of the International Labor Organization, on subjects of occu- pational health. From his staff and from the staffs of Dr. B. R. sen, Director General of the Food and Agriculture Organization, and Maurice Pate, Executive Director of the United Nations Children’s Fund, came a wealth of additional information which has helped fill in important areas of relationship with WHO. Much of this data will be presented in subsequent reports of the subcommittee. , Staff members of the Committee on Government Operations were helpful throughout—our project director, Mr. Cahn, who accompanied me throughout the nine nation tour; the staff director-chief clerk, Mr. Walter L. Reynolds, and professional staff member, Dr. Eli E. Noble- man, who attended the conferences held in Paris and Geneva, and, at my request, compiled data in Spain in the first instance and Italy, West Germany, and West Berlin in the latter instance. In bringing together needed facts on WHO for my review, one par- ticular individual is owed a special debt of thanks. Dr. Charles;V. Kidd, of the National Institutes of Health, now consultant to the Director General of WHO, worked intensively with the WHO stafl and with Mr. Cahn, in compiling many of the requested facts which will be found in these pages. In this invaluable assistance, rendered with promptness and precision, Dr. Kidd displayed the characteristic ability and devotion to duty which I have come to expect both frOm WHO and from our own National Institutes of Health. The views in this print are, as stated, my own. The large variety of data comes preponderately from WHO, notably the facts in such narrative portions as relate to the influenza epidemic of 1957 or the malaria eradication account, but the exclusive responsibility for interpretation is mine. To all those who labored long and well in helping to make available these facts, as requested, I express my appreciation. 6 UNITED STATES AND WORLD HEALTH ORGANIZATION B. THE PLAN OF THIS PRINT As previously indicated, I have approached this task by asking, first: “What are the world’s health needs?” and second, “How are these needs being met?” One cannot effectively approach the second question without initially devoting attention to the first question. That is why part I of this publication scans the world health situation. The reader’s attention is now invited, by way of background, to the 81 pages of chart and text which comprised Committee Print N o. 3, “The Status of World Health,” by this subcommittee. This ' print was also published as Senate Report 161, 86th Congress. Therein will be found information which complements and supple- ments information within part I of this report. Occasionally, there will be minor technical discrepancies in statistical estimates between the two prints. The basic reason is that both the experts of the US. Public Health Service who helped the subcom- mittee develop data for Committee Print No. 3 and the experts of WHO Who provided data for this print No. 4 are relying essentially on similarly inadequate sources, so far as reporting on developing areas of the world is concerned. Differences in base years or in date of estimates, as well as other technical factors, will account for minor differences in the two prints’ chart and statistical material. But there is fundamental agreement of course between the two studies. After part I, attention turns to the World Health Organization itself. It is described in general terms (pt. II) and then in terms of a more detailed account of some of its more important activities (pt. III). Special attention is paid to the evolution of WHO’S research efforts (pt. IV) because of the increasing significance of this aspect of health protection in the affairs of the Organization. Indeed, research has been again and again singled out in this report, in a manner suited to growing American and world interest in this topic. In part V, the assets of the World Health Organization are presented, With special emphasis on the intangible assets. The concluding part VI sets forth basic facts on WHO’S material resources. Throughout the report statistical tables and charts will be found immediately adjacent to the descriptive text. Far more could and should be said if full justice were to be done to a subject with such vast ramifications. It is hoped, however, that this print—its purely descriptive portions and of principal importance, its judgments-may serve for purposes of perspective and as a partial tool of appraisal. 0. SUMMARY OF 10 PRINCIPAL FINDINGS My 10 principal observations may be summarized as follows. These are directed not simply with respect to WHO itself but with regard to problems of disease and disability, in general. ! 1 . The world of the 20th century is science minded and health minded.— Mankind has come to believe in the power of science for good (and to fear the power of its application for evil). UNITED STATES AND WORLD HEALTH. ORGANIZATION 7 Human beings everywhere are convinced that science can add :to its previous laurels and help them to achieve still better health. Mankind is no longer resigned to sickness and disability. In recent years, it has for the first time in the history of man, become technically possible to obliterate, or hold under control, many of the historic scourges. The World Health Organization has playied an invaluable role in this process. ‘ Despite limited financial resources, WHO, with professional com- petence, has helped spearhead innumerable advances in health among the nations. Working on a regionalized and decentralized basis, it has been sensi- tive to the needs of the nations. In its first 10 years, 1948-58, it has Euccefisfully evolved in meeting the changing requirements of world eat . ‘ 2. The toll still taken by avoidable disease is shocking in its dimen- - sions.*——Despite the phenomenal reduction in disease and premature death, the grim statistics of disease and disability represent a blot on the conscience of civilization. World Health resources are still woefully inade uate in the face of health needs. In addition to obvious shortages of octors, nurses, and dentists, some of the most elemental prerequisites of environmental sanitation are lacking. A clean drinkin Well and a hygienic latrine, two indispensable elements, are virtua y unknown to hundreds of anillions of people who are, partially as a result, scourged by infectious iseases. They will remain so unless the nations of the world decide on bbld 1polilciltlas of breaking through to higher levels of activity in the field of ea t . ‘ Such decision must be carried out, step by step, year by year, by building an even broader base of health resources. A revised, up:to:date program of priorities on the part of WHO would a pear in order now. So vast are the potential calls 11 on WHO’S imited resources, especially in an organization so hig y regionalized, that only by careful, systematic planning can splintering of effort and resources be avoided and highest priority targets be ‘ et. Included among such rinci a1 targets, should be the furt er strengthening of epidemic ogical) information. Thereby, the world will come to have a far clearer, more accurate understanding than is now available of the total dimensions of world disease and disability problems. . 3. N0 country has done more for the health of the human family than 0 has the United States of America.——~With high moral purpose, we have gladly led the way in humanitarian effort in this as in so many other respects. Of course, our country gratefully acknowledges its indebt— edness to cooperation from other nations and in particular to \the scientists of countless nationalities who have contributed innumerable landmarks of discovery. But as a nation, itself, no people have contributed more generously to health through private and public means, unilaterally, bilaterally, and multilaterally than have the American people. 1 4. American membership in and strong contribution to the World Health Organization represent an asset to ourselves and to all mankind.— Out helpful presence is consistent with both our humanitarian tradi- tions and with our foreign policy aims of a world of peace, progress, plenty, and health. ‘ 8 UNITED STATES AND WORLD HEALTH ORGANIZATION Specifically, there are a number of reasons Why our service to WHO is a matter of enlightened self—interest. (a) Through the World Health Organization the United States secures the benefit of a worldwide disease warning system at a very small cost to the American taxpayer—much less than if the United States had to maintain the network itself. The influenza network, described in section 3 is a case in point which served well in the influenza epidemic of 1957. For an incredibly small direct outlay of $15,000, WHO was able at that time to send advance intelligence which saved among others, the American people literally millions of dollars of influenza ravage, not to mention incalculable intangible savings. 0 Indispensable to world security and to transportation and travel is WHO administration of International Sanitary Regulations particu— larly against six pestilential diseases—smallpox, cholera, plague, yellow fever, typhus, and relapsing fever. (b) The World Health Organization is the universally acknowledged international agency through which the health of the world is improved. The economic future of the United States depends heavily upon investment abroad and upon sales abroad. Sick people produce little, and they can bu little. (0) The Worl Health Organization helps to protect the health of all US. citizens—civilian and military—in foreign countries through protecting against the spread of disease among countries. (d) The World Health Organization can aid the research effort of this country against such high—priority diseases as cancer, cardio- vascular diseases, neurological disorders, arthritis, and diabetes through organizing studies on a worldwide basis. Specifically the World Health Organization can speed research in the United States by providing worldwide research services for scientists in the country, by arranging scientific conferences, and by insuring standardized terms and research materials. (e) WHO central technical services such as standardization in pharmaceuticals represents a cornerstone for the effective functioning of the vital American and foreign drug industry. V 5. The very fact that the United States has a tremendous stake in international health and medical research afiairs makes it doubly impor- . tant that this country have a sound set of policies relating to its total activity in this sphere—So, too, it is essential that the wide array of programs operated by various Federal agencies serve as a whole the major policy objectives of the United States, and that even more effective cooperative relationships be established with the World Health Organization. The subject of the effect of, for example, ionizing radiations, filled as it is with question marks, illustrates a topic in which there are a host of US. agencies involved at home and abroad. Cooperation with the multiplicity of foreign agencies is especially essential here, as will be noted in my 10th point. Overall medical research is in a state of dynamic transition through- out the world. Discoveries are being made With such breathtaking rapidity on so many fronts through so many sources that it is obliga- tory that the full potential of scientific promise be realized With efficiency and teamwork. UNITED STATES AND WORLD HEALTH ORGANIZATION 9 6. Specifically, the US. Public Health Service which has admirably evolved as the world’s leading such instrument of health advances, must now be enabled further to improve the situation—Needed now, for ex— ample, is favorable action on proposed legislation, Senate Joint Resolution 41, 86th Congress, sponsored by Senator Lister Hill and other Senators including myself. The purpose of this bill is to sup- plement the existing National Institutes of Health by the establish- ment of a National Institute for International Medical Research. Such a new Institute would find that it could and should work in closest liaison with WHO. The Organization could cooperate with the Institute with worldwide modus operandi of cooperation virtually unIaIt(t)ainable except through multilateral auspices such as those of W . The implementation of this legislation, with closest relationship to WHO, could serve as a major determinant of the future of world medical research. Similarly, ample legal authority should be confirmed as residing within the hands of the Surgeon General of the US. Public Health ’ Service in cooperating through the Department of State with WHO and otherwise in protecting America’s health on the world scene. Notable contributions already made by such organizations of the Public Health Service as the Division of International Health and the Communicable Disease Center in Atlanta, Ga, can and should be further facilitated. 7. An adequate future level of financial resources of WHO represents a major policy problem of short and long range not simply for the health oflicials of the respective nations but at the highest executive echelons 0 all governments—As indicated in my second observation, WH would be the first to admit the limitations imposed by its existing modest resources. Its funds must be spread so thinly throughout the world, especially among the developing nations, that by present time— tables, it will be a long time before the mantle of avoidable diseases over mankind will be appreciably lifted. From a regular budget in 1948 of less than $5 million to a budget 10 years later of $13.5 million is a considerable increase. Yet, inflation has taken its toll. Moreover, in the “revolution of rising expectations” throughout the world, disease-stricken peoples and their leaders understandably expect more than promises of better health, a generation or more distant. It is, however, precisely in the developing nations that even present modest levels of assessed contributions to WHO and their voluntary participation in a special program like malaria eradication—presents heavy financial burdens. Improved health is but one of the pressing demands which their inadequate national budgets must seek to cover. To be sure, money does not represent the whole problem. Scientific and other advances have never been exclusively deter— mined by the amount of money available. The heads and hearts of men, their organization, their procedure, their timing crucially shape the effectiveness of medical and other sciences. But adequate financial resources are essential. The sums of money which the United States itself has contributed to WHO represent essential, sound, but modest investments, to date. 3‘8‘516—59———2 10 UNITED STATES AND WORLD HEALTH ORGANIZATION It may be stated that, dollar for dollar, our own expenditures through WHO have probably served about as effectively as money spent in any other health or nonhealth channel of Federal activity. The US. contribution to the World Health Organization in 1958, aside from voluntary contributions to special accounts, was $4.7 million. This figure should be borne in mind against the perspective of our overall $77 billion budget contemplated in the current fiscal . 'year.. . Further facts which provide perspective to our modest con- . ' tribution to WHO are: (a) The Congress is now evaluating a proposed mutual security budget of 1960 of $3.9 billion, of which $1.6 billion would be for arms; (6) in the 1959 fiscal year, the Federal Gov- ernment spent $2.8 billion for all health programs for our people; (c) in 1958, the United States was spending for medical research alone, within continental United States, through public and private sources, $330 million, wholly aside from other expenditures of a health nature; (d) by 1970 the figure for total US. medical research spending, public and private, in the United States may reach $1 billion. If one were, therefore, to gage our future role in WHO solely against the yardstick of our interest in medical research, as such, it is clear that we are hardly overspending for this great organi- zation. Or by the measuring rod of overall US efforts for security aid abroad, we are hardly overcommitting ourselves to WHO. In- deed, we are underallocating our resources to world health. However, the future level of WHO’s financial support must be faced squarely by all the nations which have the capacity to increase their present support. N 0 one nation—the United States—or anyone else should have to sustain virtually all of the burden—in the malaria eradication special account, or on many of the other specific needs which are now emerg- ing, e.g., for improved water systems throughout the world. 8. So far as the United States is concerned, WHO—stimulated research in major killing and crippling diseases like cancer and cardiovascular disorders is a subject of highest importance—Provision of funds by the United States in 1958 to permit WHO to plan a more extensive inter- national research eflort was an act of statesmanship. ' The WHO has not hitherto been able to make a major eifort to stimulate medical research on a worldwide basis, a fact which points to an obvious but understandable gap in the work of the young organi- zation. Experience gained over a decade with research programs almost entirely related to WHO’S disease control activities has, how- ever, prepared the way for a research program with a wider base, encompassing the major chronic diseases—such as cancer, heart dis- ease, and arthritis—as well as the communicable diseases. The scientific needs and opportunities are impressive; the disease problems are urgent; the nations are eager to cooperate. Coming up for consideration by the 12th World Health Assem- bly is a specific proposal for an International Public Health and Medi- cal Research Year. Such a year could supply a significant stimulus to the various nations to break through to higher levels of research support and cooperation. Naturally, the value of any such break- through could only be meaningful if it were sustained and advanced indefinitely, rather than allowed to retrogress or stagnate. 9. Perhaps most important of all, WHO’S value as a means of advancing world peace should not be underestimated.-—Cooperation in the healing UNITED STATES AND WORLD HEALTH ORGANIZATION 11 arts can heal more than the ravages of disease; it can help, and has helped, if only partially, heal the tensions, the misunderstandings, the anxieties of a world divided by idealogy and to a lesser extent by nationality, culture, and other factors. For the forseeable future, the realistic approach to relationship between the United States, the U.S.S.R., and nations associated with or neutral toward these two great powers is through seeking a series of limited areas of accord. A total general settlement of all differences cannot be anticipated. Cooperation in limited matters, in health, for example, and particularly in medical research, is tangible, specific and productive. It works. It has worked. This, therefore, is one of the areas which must be sought out and encouraged as a means of sustain- ing and broadening cooperation between East and West. 10. The record of the World Health Organization commands the respect and admiration of men of good will everywhere.——Its future record can be still brighter with fulfillment if each nation and if gifted public and private organizations cooperate with it to the est. So, too, the many intergovernmental organizations which share with WHO interests in selected fields of health—UNICEF, FAO, 1L0, UNESCO—must maximize efficient coordination with it if the world’s inadequate health resources are to be channeled as well as human ingenuity and devotion will permit. Jurisdictional lines e.g., with UNESCO, which may once have been valid, have tended to become blurred with time and require constant reexamination. With respect to cooperation from private organizations, WHO has reaped immense benefit and has given benefit. Indeed, one of WHO’S greatest strengths has been its working relationships with nongovernmental organizations. But here, the potentiality of further fruitful cooperation is still enormous, especially with voluntary groups composed in part of laymen. Too, WHO’S formal relationships with professional, technical, medical groups have been immensely rewarding. But, the future of medical research, in particular, embraces new disciplines and combi- nations of disciplines—notably amon physics, chemistry, and biology. It is here that uncharted realms of uture cooperation lie. Part I WORLD HEALTH—STATUS AND RESOURCES A. THE CHALLENGE The World Health Organization defines health as “a state of com- plete physical and mental well-being and not merely the absence of disease or infirmity” (preamble of WHO Constitution). Furthermore, “the objective of WHO shall be the attainment by all people)s of the highest possible level of health” (article 1 of the consti- tution . Four tools are used to attain these goals: promotion of health, prevention of disease, medical care, and rehabilitation. The types of human disease are so diversified, however, and inci- dence so widespread and often so relatively uncharted, that to attain a rapid picture of the world’s health problem at the outset is not easy. Some general aspects soon emerge, however, on how far mankind has come and how far it still has to go to lift the mantle of sickness from human beings. Situation in emerging areas Inevitably, discussion of worldwide problems turns from the needs of highly industrialized nations to the plight of peoples in the develop— / ing areas of the globe. Two out of every three of the 2.7 billion people in the world live in the emerging or underdeveloped areas. Available statistical studies confirm the low median age, the short span of life and the increasing increments of birth over deaths as characteristics of these population groups. With few exceptions the basic economy is agriculture and produces less than one—third of the world’s income. This economic poverty is an artificial rather than a natural phenomenon, since these areas contain both the natural resources and the manpower necessary for creating wealth. Side by side with economic poverty are wide- spread illiteracy and human illness. First to suffer are the growing minds and bodies of children. Hun— ger stalks them from birth onward. Of the estimated 750 million children in underdeveloped areas, 60 percent live in countries where the national income per head is less than $100 a year; 17 percent live where it is from $100 to $200; and 23 percent where it is over $200. Into this scene of widespread wants and illness among young and old, come sounds and sights of today’s age of high-speed transporta- tion and communication. Space and time are shrunken by technology. Jet plane travel now makes a diseased, helpless indigent of a swarm— ing ancient city of the East, virtually the next—door neighbor of Ameri- cans in newly built middle-income suburbia. Disease knows no frontiers, nor does compassion for the afflicted nor enlightened self-interest. Disease today is, therefore, a matter of concern for all mankind. 13 14 UNITED STATES AND WORLD HEALTH ORGANIZATION Toll of a cholera epidemic A symbolic episode from recent history ma be recalled. At El Korein, in Egypt, on September 22, 1947, 3 aborers, among some, 6,000 workmen engaged in construction, contracted dreaded cholera. Nearby, from all the Egyptian provinces merchants had gathered for the annual date fair at this center on the eastern edge of the Nile Delta. With the dreaded news of the outbreak of cholera, came panic and flight from El Korein. Within days, dispersion of merchants and workmen brought sudden death to new cities. By October, the whole of Egypt was involved and a specter literally confronted the world. Fortunately, international action was promptly forthcoming. The WHO did not then even officially exist; it was still an interim commis- sion. But lightning-fast action by the Section of International Quar- antine, long a major element of the old League of Nations, coordinated the worldwide counterattack against the scourge. A cholera airlift of vaccine made medical history. From all over the world came su plies and specialists. y February 18, 1948, the signal went out from Geneva, “Egypt now declares whole country free from cholera.” The death roll had been 20,472, but Egypt and the world had been saved infinitely worse heartbreak. In September, at the time of the outbreak, only 19 countries had ratified their membership in WHO. It could not formally exist until 26 nations did so. Before the “all clear” was sounded, however, 10 more had ratified and the stage was set for the first World Health Assembly to meet on June 24, 1948. On April 7, 1948, the WHO Constitution had come in force—an historic instrument born of necessity and of man’s humanity to man. B. THE RESPONSE—PAST SUCCESSES The world today is a healthier place in which to live than ever before in the recorded history of man. This is the great overriding conclusion apparent from the network of world disease and vital statistics, as established by the World Health Organization. Indeed, the first words of the world’s standard statistical series on these matters, the United Nations Demographic Handbook (1957) were as follows: The reduction achieved in mortality during the last several decades is by now a well-known phenomenon * * *. The dramatic declines in the death rate which some of the underdeveloped areas have experienced have no precedent in the history of mortality among the countries of the world which now enjoy the lowest rates. / The population of the world has increased (as of mid-1957) since mid-1955 by about 47 million inhabitants * * *. This rate of population growth has been brought about almost entirely by a decline in the death rate, rather than by an increase in the birth rate. The resources devoted to health outlined hereinafter, scanty as they are in some parts of the world, have produced remarkable results. These resources, apart from those directly devoted to health, include education, technology, transportation and the other aids to physical well-being. In toto they tend to lift levels of health. For all practical purposes the environment of man has been con- trolled and improved beyond measure by the development of mechan- ical devices. The range of the habitable world is being extended year by year by developments in central heating and air conditioning UNITED STATES AND WORLD HEALTH ORGANIZATION . 15 and protection through modern insulation against excessive heat and cold. New methods of land irrigation devised by man’s ingenuity and perseverance have greatly enlarged the scope and range of food production. Water has been harnessed for the production of elec- tricity, and for land irrigation in zones which would otherwise be arid. The sea itself has been swept out to provide more fertile land; it has been explored for many of its treasures of food and is now being brought into subjection for the production of heat and power. To these powerful forces have been added modern health services and modern preventive and treatment measures. Decline of infectious diseases The elevation of levels of health has been worldwide, and not con- fined to industrialized countries. The striking contribution which, for example, the countries of the 'Middle East have made during the past decade to the health of their own peoples has been in the con- quest of major epidemic diseases. There have been notable victories over cholera. But the most sustained progress has been made against malaria, a subject discussed in part III. The challen e is still great. Village and small-town populations are still gravey hampered by debilitating endemic diseases which can be cast out only by improved water and sewera e supplies, a marked improvement in housing and other environmenta conditions, and by the Widespread impact of health education. There is an urgent need to train and employ far more, medical, nursing, and auxiliary person— , nel. The developing areas of the world are characterized by such wide— spread variations in culture and tradition, in land and climate, that it is hard to generalize. Some clear general gains are, however, evident: Malaria is being defeated. Tuberculosis (chart 1-A) and smallpox (charts 1—B and 1—0) are declining. Cholera is on the way out, as indicated b sharp declines over the past decade (chart 1—D). Similarly, p ague, the “Black Death” of the Middle Ages is being ,, defeated (chart 1—E). Finally, there has been a steady decline in typhus all over the world (chart l—F). Particular attention should be devoted to the latter scale which shows not only sharp declines but the rate at which the declines occur. . Eflects of rising health levels f One general effect of rising health levels has been a prolongation of life in both industrialized and unindustrialized areas of the earth (chart 1-G). In India, for example, the average male born in the decade 1921—30 lived only 27 years from birth. But males born over the decade 1941—50 will live an average of 33 years after birth. Even the much longer average life span in countries with high per capita in- comes has been growing longer. Another general effect of rising general health levels has been a general dechne in infant death rates. Even in countries where infant eath rates have been low for decades, the declines continue (chart l—H). Infant mortality is in all probability declining throughout the world. For example, infant mortality rates during the past 10 years in Mexico City, Sao Paulo, and a number of other crowded areas in first]? America have fallen for the first two below 100 per 1,000 live irt s. 16 UNITED STATES AND WORLD HEALTH ORGANIZATION However, the current state of vital statistics throughout the world is such that birth and death records in many parts of the world are inadequate. Indeed, as was pointed out in the committee print, “The Status of World Health” and as will be pointed out later herein, one of the tasks of the World Health Organization is to help countries improve their records so that a clearer picture of the health of the world will be available. The ravages of infectious disease The earlier committee print confirmed, however, that the world health situation offers no cause for smugness. The rates for some infec— tions diseases shown above are vastly higher in many countries with low per capita income and unfavorable climates than in northern Europe and the United States. As will be shown in detail in later sections, the infectious and communicable diseases remain the major health problem over large portions of the globe. CHART 1—A PROPORTION or DEATHS no» TUBERCULOSIS AND omen INFECTIOUS DISEASES IN TOTAL NUMBER OF DEATHS: "20 AND "56 % (Exeludlng “Eldon” and vlolmco) 13 1920 1956 1920 V 56 1920 ' 1956 l ‘1920 1956 UNITED STATES SWEDEN ENGLAND AND WALES ITALY no % 13 12 solo CHART 1—B NOTIFICATIONS OF CASES OF SMALLPOX, l94B-l957 [a . ”Io // “lg/’44 / - ’% SMALLPOX IMO-"I1 Anna! Ant-cola“: < 1' 1-7 In.” I”.M \\\\\\\\\\\\\\\\\\\\\\\\\\\\§ 'W soo> "iII005 “chum Mug-uh“. mwwm NOILVZINVSHO HLTVEIH (I'IIIOAA GNV SEICLVJS CIGLLINII LI 0mm 1—0 SMALLPOX 19461957 ToIal of officially milled can: by cominqms 500000 400 000 300 000 200 000 ‘ 100000 ' 409000 1948 1949 1950 1951 'E_xél.' USSR and Comm-mil China Amllta Puklslun lnclla and A‘l“ . 1952 1953 ' 1954 1955 1956 1957 500000 400000 300 000 200 000 100 000 VI "0 I505 SI NOIZLVZINVDHO HL'IVEIH G'IHOAA (INV SHLVLS CEILIND. CHART 1—D NOTIFICATIONS OF CASES OF CHOLERA, I948 AND I957 dZHHHU mabgm >26 dQONHB Egan OMQENEHHOZ. Ho W///////%n % . % ‘ % _ % / A 2-25 12.2: -Ioo.m CHOLERA 1948 and 1957 , Rowkod cuul: m. w Iooooo won'lon % o Wmmmmm _ __ __ _._._._._ __.__________: ' CHART l—E PLAGUE: REPORTED CASES, I957 CAsEs-us- we; 1:] Me I >Ia O {sawdust-cum OZ NOILVZINVBHO HL’IVIIH (I'IHOAA CINV SELLVLS CEILING. CHART 1-F REGRESSION 0F TYPHUS Cans oi lows-homo typhus "ported from 1945 to 1957 (logarithmic scale) . 1 CASES A man Nék‘m AFRICA (Mu-«ohAlwh, Tunlglc 6 Egypt) vucos'uvu U.$. AFRICA 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 CASES 40 0M 20m 5000 4000 2000 ME ss's‘ 20 10 no .206 NOILVZINVDHO HLTVSI—I (I’IHOAA (INV SELLVLS (IELINLCL IZ mm CHART l-G EXPECTATION OF LIFE AT fllRTH 62.ng webs—Em >26 $5wa Egan Oflaatfioz AGE AGE 70 60 50 40 30 20 10 CEYLON INDIA JAPAN FRANCE SWEDEN UNITED STATES Dmll ran not 1000 population CHART 1—H DEATH RATES, INFANT DEATH RATES, mo AND use 1920 1956 1920 UNITED STATES SWEDEN ENGLAND AND WALES FRANCE no Mu lfloumhmfivlmllnbkflu NOILVZINVBHO HL’IVEIH (I’IHOAA (INIV SELLVJJS HELLINfl 88 24 UNITED STATES AND WORLD HEALTH ORGANIZATION Difficulties have been complicated by the phenomenal growth of population throughout the world during the past two decades. For example, Calcutta has grown from 1,197,000 in 1931 to 2,548,677 in 1951; Delhi from 348,000 to 1,191,104, and Karachi from 248,000 to 1,009,438 in the same period. And so the tale is being told with ever-increasing urgency. Malaria, despite recent advances, after 10 years, 1947-57, still holds the first place as a maker of poverty, de ression, and chronic ill-health of body and mind. The control of tu erculosis is rendered difficult because of the poverty of the people, wretched housing con- ditions, lack of sanitation, and overcrowding in both town and countryside. Meanwhile half-empty stomachs characterize much of the world and nutritional deficiency and illness remain widespread. Problems in industrialization Industrial progress is no doubt over the long run the means of gen- erating the income necessary to cope with disease. Yet, industrial— ization typically generates health problems, especially when the speed 'is abnormally high. The movements of people in the direction of new sources of employment must be carefully watched, in case it outruns the capacity for absorption in newer centers. Overcrowding of families in cities is a danger to health in an im- mediate physical sense. As countries develop in numbers, there is a growing movement from rural areas to towns. This is greatly ac- celerated when rapid industrial progress takes place. Unless careful and farsighted plannin is undertaken in good time, health conditions deteriorate progressive y with urban growth, as was evident in the great industrial cities and manufacturing towns of the West European countries in the 19th century. It may be said in general terms that before the 20th century health conditions throughout the world, as reflected in general, and infant death rates, were worse in urban than in rural areas. What is more, these conditions in the crowded unplanned cities actually deteriorated as time went on, until strong environmental health measures were taken. The inhabitants of crowded areas suffered more from recur- rent epidemics of the major diseases like cholera, plague, yellow fever, and smallpox than their rural neighbors. Since the beginning of the present century, a remarkable change has taken place in the more organized industrial towns. This has occurred to such an extent that in the majorit of those countries for which reliable data are available, the genera levels of health are rather higher in the major cities than in the country as a whole. This improvement has been due in the first instance to the great ad- vances in environmental sanitation which took place towards the end of the 19th century, and in the second place to the rapid developments in the personal health services which were an outstanding feature of the present century. ’ Unfortunately, the evidence suggests that the changes for the better are ill—distributed. In the less-developed countries which are now undergoing rapid urbanization, environmental advances have frequently failed to keep pace with the needs of the growing popula- tion, and health personal services have lagged far behind. UNITED STATES AND WORLD HEALTH ORGANIZATION 25 Changing problems in industrialized countries The more economically developed countries can hardly be said to have solved their health problems. They have simply changed them. In these areas more and more attention has had to be paid to the chronic degenerative and malignant diseases. The span of life has extended, and these diseases and the eneral care of the aged have become important functions of the health authority. During recent years, the chronic, degenerative diseases have been increasingly studied, but so far no general means of prevention has been discovered. The important changes in the age composition of the population in technologically advanced countries, including the United States, leads to an increased liability to the diseases of old age. Cardiovascular ravages The cardiovascular diseases1 affect, in the main, middle-aged and elderly persons. Their incidence is therefore profoundly affected by age distribution. There may, for example, be a relatively low overall mortality from this group in a country with a high birth rate and therefore a high percentage of young people. At the same time, age— specific death rates show cardiovascular ailments to be important causes of death. Thus the general mortality from heart disease is much lower in the Netherlands than in Norway. Rates per 100,000 of the total male population in 1957 were 306 and 358 respectively. But mortality for men above 40 is about the same in both countries (932 and 936 respectively). This is due to the fact that young people and children constitute a much higher percentage of the population in the Netherlands. Again it has been shown that in almost every country for which data are available and for all age groups male mortality from cardio- vascular diseases is higher than female mortality. For both sexes there is a rapid increase with advancing age. Degenerative heart disease is now the most frequent cause of death in North America, in most of Europe and among the more prosperous groups of the popula- tion in the other parts of the world. This cannot be explained solely as the result of the reduction of other causes of death or of the changing structure of the population. Some other factor must be involved, probably connected with modern modes of living, and possibly with some particular item in the diet. The unsolved problem of cancer 2 The increased incidence of cancer of the respiratory system has given rise to much speculation in recent years. The development is most striking in highly industrialized countries. Among women the mortality from this form of cancer is much lower than men and is also increasing less rapidly. As in deaths from cancer of the lungs, mortality from cancer of the digestive organs is also higher among men than among women. (Incidentally, a future subcommittee print will be devoted to the worldwide incidence of cancer.) 1 See pt. IV, sec. E(4) (b) on WHO classification of cardiovascular disease status and consideration of diet problems. . 1 See pt. IV, sec. F.(4)(a) as regards WHO when on the cancer front. 38516—59——3 26 UNITED STATES AND WORLD HEALTH ORGANIZATION Respiratory ailments In populations in which the expectancy of life at birth is high, one must also regard as inevitable an increase in the more chronic respira- tory diseases. A good deal of epidemiological research is now being devoted to this subject. In England the 16 million male industrial workers had 4,625,000 episodes of sickness and injuries in 1953—54 which lasted for four or more days. This represented a total of over 200 million lost working days. Ten percent of this certified incapacity to work was ascribed to bronchitis (20 million days), asthma accounted for a further 3 mil- lion days. Rheumatism, arthritis, sciatica, etc., accounted for 17 million days, and no doubt many of these were diseases occurring in the latter half of working life. At ages between 45 and 64 years, the acute respiratory infections in terms of incapacity for work in men represented about 15 percent of the total; bronchitis, 17 percent; arthritis and rheumatism, 15 percent; injuries accounted for a further 16 percent. Mental and neurological ailments A vast and largely uncharted realm is the field of mental and neuro— logical disorders, including cases of actual brain damage. In the United States, where statistics are most complete, more than 550,000 persons are in hospitals for mental disease (occupying one-half of all the hospital beds in the Nation); another 130,000 mentally deficient individuals are in institutions. Uncounted millions are the victims of disorders of the central nervous system. « In other countries, with the exception of a few like the United Kingdom, statistics on mental and neurological problems are un— fortunately so inadequate as to be almost useless or misleading. In any event, due to the aging problem more cases of mental dis— order, such as arteriosclerotic and senile psychosis are expected to occur and require treatment. On the other hand, there are indica- tions that psychological stress and conflict resulting from changing social conditions may give rise to increasing mental health problems, including those associated with the recent increase of juvenile delinquency. High accident rate On another front, in countries covered by a recent WHO study, accidents of all kinds were responsible for between 2.4 percent and 7 percent of all deaths, with the rates running hi her for men than for women. The increasing use of machinery an the expansion of motorized traffic and transport have been accompanied by a con- stantly increasing accident rate in the more developed countries. Special attention is being given in many countries to the stud of physical, physiological, and psychological problems involve in accidents. v In summary, there have been astounding advances in the state of the health of the world over the years just past. Man problems, however, remain unsolved and the solution of many prob ems simply generates others. a An importantnew listing of diseases To give a comprehensive idea of the extent of problems still to be solved, I asked experts in the World Health Organization to examine UNITED STATES AND WORLD HEALTH ORGANIZATION 27 the total range of communicable disease problems in five areas— Africa, North America, Central and South America, Asia, and Europe. The results, difficult but helpful, are summarized in table l—A. Since time was pressing, data for the table was gathered within so necessarily brief a period that the table cannot be construed as definitive. By its very outline nature, moreover, it is open to some differences of interpretation. Nevertheless, I regard this table as extremely important and illuminating. It comprehensively conveys a sense of the Wide range of disease and of the diverse answers to disease. It is recognized that experts may and Will differ as to specific priorities to assign toward individual disease solutions. But the underlying facts reflected in the table Will it is believed, meet with accord. ’ The table shows that there are numerous diseases Where the simple application of public health practices can reduce the problem or obliterate it. But, the table also shows literally dozens of infectious diseases in various parts of the world that will require intensive research before disease control can be fully effective. I earnestly hope that this global mapping of the status of knowledge relating to diseases and the possible priority requirements for control of disease might be extended over a period of time as a major guide to those who must make decisions on the allocation of funds for disease control. TABLE 1—A.—Infectious disease problems, by continent SECTION 1.—AFRICA Efiec- Priority requirements for progress Eflec- tlve pre- Methods tive vention Disease _ Cause of spread treat- available Socio- known under- ment (biologi- mum-mi- Trained stood known calor Research develop- person- Finances chemi- ment nel cal) vnzus AND RICKETTSIAL Smallpox .................... + + — + 3 2 1 1 Yellow fever. .... + + -— + 1 2 2 1 yp us......-- .-.. + + + + 4 1 2 2 Poliomyelitis ................ + 7 -— ‘I l 4 2 2 Insect-borne encephalitis..._ + ? - — 1 3 1 2 Dengue and other insect- + borne virus diseases- . ? ? — — 1 3 1 2 Haemorrhagic fevers ? — — — 1 3 1 2 ' + ? + ? 1 3 1 2 Virus hepatitis _____ .. — ? -— — 1 3 1 2 Virus meningitis and other diseases due to enter-ovi- ruses ...................... 'l’ ? - —- 1 3 1 2 Virus diseases of childhood: mumps, measles, rubella -- + + -— 1 3 2 + + 7 1 3 l 2 Adenovirus infectio + ‘I ‘l 1 3 1 2 Other res iratory virus in- fections eluding common ....................... 'I 1 — — 1 3 1 2 Glandular fever- . — — —- — l 3 1 2 Trachoma ‘l’ ‘P + - 2 1 2 2 Epidemic con unctlvltls, in- cluding and bacterial. T 'I + — 3 1 2 2 Rabies ...................... + ? ? ? 1 ‘ 4 3 2 -|——lmown -—not known f—doubtful Priority—estimated by number 28 UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE 1-A.——Infectious, disease problems, by continent—Continued SECTION 1.—AFRIOA—Oontinued Disease Cause known Mnfhnfln oi spread under- stood Efleo- tive treat- ment known Efleo- tive pre~ Priority requirements for progress ventlon available (biologi- cal or chemi- cal) : economic Research develop- Socio- ment Trained person- nel Finances BACTERIAL DISEASES Diphtheria .................. Tetanusnn Stre tococcal infections“ Step ylocoocal infections Pneumonia ............ Acute and chronic bron Cerobrospinal fever coli .......... ..... Tuberculosis ................ Bruoellosis .................. FUNGUS DISEASES Dermatomycoses ............ Histoplasmosis .............. VENEBEAL (momI or INFECTIONS Yaws ........................ Endemic syphilis and re- lated conditions ___________ Venereal syphilis ............ Gonorrh ea.. Nongonococcal urethritis — and related conditions ..... Pnorozosn DISEASES Arneblasis ameblc dysen- Sleepifié's’l’ciifiéééjiiiiiliiiii Leishmanlesls: Toxoplasmosls ............... WORM msmssms Hookworm .................. Round worm ................ Bllharziasis (schistosomlasls) Draoonilas _________________ Enterobimis ..... Opisthorchiasis.- Paragonimlasis . . pe Onchoceriasis ( b filiariasis) ..... Wuchererla elaphantias Loaiasis (Calabar’s swelling). av; ++++ +++ +++~++++++ ++ ++ + ++++++ - +++-++I +++--+++ “r +++~ w :++ ++ ++ + ++++++++ +*+~+~+-+ ~+++ ++l * ++ -++ + ~e-ova ne-e I"° a 4| l-o-o—a-e-a 1"”! l‘l”+++ ~++~ +~x I ll ., "III Hz“: Il"+l lllillll new HNHH e-u-H—n «mosh-wH-aeeush NM H I-‘h-fi e-n-n-Io: i—I D-‘NN (an I-ID-t I-I NNNWNENN bah-INN “LN” NNWWMNNNMN 0710M H03 ufi the“ ##ODN N “H Nil: N NNNNHHHH teem-u— Hun- n-u-u-u-u-u-n-n—u—u-a v-n-a (A, 6:03 WWNW N) HHH HR) Dbl-l N NMIOIOHNNN “NI-IN NHL? ”NNNMNNHN’M“ M10 N) NM MMWH H NNN MIG e-u-I I-l NNNNNNNN UNITED STATES AND WORLD HEALTH ORGANIZATION 29 TABLE 1—A.——Infectious disease problems, by continent—Continued SECTION 2.—NORTH AMERICA Eflec- Priority requirements for progress Efieo- tive pre- Methods tive vention Disease Cause of spread treat- available Socio- known under- went (biologl- m......ui. Trained stood known cal or Research develop- person- Finances chemi- ment nel cal) vmus AND monument. Smallpox .................... + + — + 3 4 4 4 Yellow sfever ................. + + — + 1 4 2 2 ..................... + + + + 2 2 1 2 Poliomyelltis ................ + '1' — '1' 1 3 2 3 Insect-borne encephalitis...- + '1’ — — 1 3 1 3 Dengue and other insect- _ borne virus diseases ....... {i 7 1 3 l 3 Haemorrhaglc fevers ......... ? —- — —- .................. Rickettsial diseases .......... + 7 + '1’ 1 2 1 2 Virus hepatitis .............. — 7 -— — 1 2 2 Virus meningitis and other diseases due to entero- viruses .................... ? ? — — l 2 2 3 Virus diseases of childhood: mumps, rubella, measles, chickenpox ................ + + — 1 1 Influenza .................. .. + + 'I 1 4 2 3 Adenovirus infections ....... + ? 7 l 4 2 3 Other respiratory virus in- fections, including com- mon cold __________________ '1’ ‘1’ — — 1 4 2 3 Glandular fever.......--.-.- — — -— — 1 4 2 3 Psittacosis ................... + + + — l 4 3 2 Rabies ______________________ + ? ? ‘I 1 4 3 2 Qfev ...................... + '1’ + — 1 4 2 3 Spotted fevers (rickettsial) . . + ‘1’ ? ? 1 4 2 3 BACTERIAL merciless Diphtheria .................. + + + + 4 3 1 2 Tetanus ..................... + + 7 + 4 3 1 2 Pertussis .................... + + 7 + 3 3 I 3 Streptococcal infections ...... + 'I + 7 l 3 2 2 Staphylococcal infections. --_ + ’1’ 7 - 1 3 2 . 2 Pneumonia .................. + '1’ + 'I 2 3 1 3 Acute and chronic bronchi- _________________________ ? 7 — 1 3 2 2 Cerobrospinal fever.-. + + — 3 8 l 2 Salmonellosis ......... + 7 ? 2 2 1 2 Shigello sis ___________________ + + -— 3 2 1 2 Enteritis due to Escherichia coli ........................ + — — — 1 3 1 2 Anthrax ..................... + + + 7 1 4 3 2 Brucellosls __________________ + + 'I 7 1 4 3 2 Bacterial food poisoning... + + '1’ — 1 4 3 2 Leptosplrosis ................ + + 'I '1’ 1 4 3 2 Lls in is + — —- — 1 4 3 ‘ 2 + + + r 1 4 3 2 + + + + l 4 2 3 Plague ...................... + '1’ + + 1 .................. 1 swans DISEASES ’ Coccidiomycosis ............. + ‘P — — 1 1 Dermatomyooses ............ + 7 — — 2 1 1 2 Histoplasmosis .............. + ‘P — —- 2 1 VENEREAL GROUP or INFECTIONS Venereal syphilis ............ + + + — 1 3 2 3 Gonorrhoea .................. + + ‘1’ — 1 4 3 2 Chancroid ................... ? + ? ? 1 4 3 2 Lymphogranuloma vene- reum ...................... + '2 + ’I 1 4 3 2 Granuloma lnguinale ........ + 7 + '1’ 1 4 3 2 Nongonococoal urethritis and related conditions ..... — — ? — 1 4 3 2 Pinta ........................ + —- + 1 3 3 2 30 UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE l-A.——-Infectious disease problems, by continent—Continued SECTION 2.—NORTH AMERICA—Continued Eflec- Priority requirements for progress Eflee— tive pre- Meflmfls tive vention Disease Cause of spread treat- available Socio- known under- ment (biologi mmumi- Trained stood known cal or Research develop— person- Finances chemi~ ment nel cal) PBOTOZOAL DisEAsns Amoebiasls_. + + ? —- 2 3 2 + 7 7 2 2 1 2 + ? — 2 2 1 2 Toxoplasmosls ............... -- ? — 1 3 1 2 HELMmrmc DIsEAsEs Ancylostomiasls ............. + + ? -— 2 1 2 2 Ascariasis .................... + + 'i -— 2 1 2 2 Bilherziasis (Schistosomia- ‘ + ‘I -— 2 1 2 2 + ‘P — 3 2 2 2 A + ? — 2 2 2 2 Trichinosis __________________ + — ? 1 4 3 2 SECTION 3.—-CENTRAL AND SOUTH AMERICA vuws AND BICKETTSIAL Smallpox-__. + + — + 4 2 1 2 Yellow fever + + - + 1 2 1 2 + + + + 3 1 1 2 + ‘I -— ‘I 1 3 1 2 tis _ + ‘i —— — 1 3 1 2 Dengue and other insect- borne virus diseases _______ +(?) ‘I — —— 1 3 1 2 Hemorrhagic fevers __________ 7 —- — —- 1 3 1 2 Rickettsial diseases __________ + 7 + 7 l 3 1 2 Virus hepatitis .............. — 'I — - 1 2 1 3 Virus meningitis and other diseases due to entero- viruse .................... ? ? - -— 1 3 1 2 Virus diseases of childhood; mumps, rubella, measles, chickenpox ________________ + + — — 1 2 1 2 Influenza ............ _ + + — ? 1 3 1 2 Adenovirus infections ....... + ‘i — ? 1 3 1 2 Other respiratory virus in- fections including com- ? ? —— —- 1 3 1 2 - - 1 - i 3 1 2 + + - 3 1 + 7 '1’ ? 2 2 1 2 + ‘2 + — 1 3 1 2 + ‘I ? ? 1 3 1 2 'I ‘I + — l 2 1 1 BACTERIAL DISEASEs Diphtheria .................. + + + + 4 2 1 2 Tetanus__ . + + '1 + 4 2 1 2 Pertussis. + + 'l + 3 2 1 1 Stre tocoocal infections. + ? + 7 1 2 1 2 Stop yloooccallnfections___. + “I ‘I - 1 2 1 2 Pneumonia .................. + ‘I + 1‘ 3 2 1 2 Acuteand chroniebronchitls ? 2 ? -— 1 3 1 2 Cerebrospinal fever .......... + + + - 3 3 1 2 Salmonellosis ..... + + ? l‘ 2 2 l 2 Shlgellosis ___________________ + + + — 3 2 1 2 Enteritis due to Escherichia “’" i l ; r i 3; i i + + 1’ ? 1 2 3 2 + + 7 — 1 1 3 2 + + ? l’ l 3 2 3 + — — — 1 3 1 2 + + + + l 4 l 2 ‘ + ? + - l l l + + + + 1 2 2 1 UNITED STATES AND WORLD HEALTH ORGANIZATION 31 TABLE 1—A.——Infectious disease problems, by continent—Continued SECTION 3.—-CENTRAL AND SOUTH AMERICA—Continued Eflec- Priority requirements for progress Eflec- tive pre- Methods tive vention Disease Cause of spread treat- available Socio- known under- ment (biologi- mun-nix Trained stood known cal or Research develop- person- Finances chemi— meut nel cal) FUNGUS DISEASES Dermatomycoses ............ + 7 - - 2 1 1 2 Histoplasmosis .............. + 7 — —- 2 3 1 VENEREAL GROUP or INFECTIONS Venereal syphilis ............ + + + — 1 3 2 3 Gonorrhea ........ + + 7 — l 4 3 2 Chancroid ................... 7 + 7 7 1 4 3 2 Lymphogranuioma vene. reum ...................... + 7 + 7 1 4 3 2 Granuioma inguinale ........ + 7 + 7 1 4 3 2 Nongonomccal urethritis and related conditions ......... - — 7 — 1 4 3 2 Pinta ................. + ~ + 1 3 3 2 Yaws ........................ + 7 + — 1 2 l 2 rnorozoeL DISEASES Amoebiasis .................. + + 7 — 2 3 2 2 Trypanosomiasis (Ameri- can) ....................... + + 7 -— 2 2 1 2 Leishmaniasis: Cutaneous ............... + + 7 — 2 2 1 2 Visceral- _ _ . + 7 -— 2 2 1 2 Toxoplasmosis ............... — 7 — 1 3 1 2 KELMINTHIC DISEASES Hydatid disease ............. + + — ‘l 1 2 1 2 Trichinosis .................. + + — 7 2 3 1 2 Onchocereiasis (blinding 11- ~ lariasis) .................... + + 7 7 1 2 2 1 Wuchereria infection (pro- ducingeiephantiasis) ...... + + ? 7 1 2 1 2 Dracontiesis .......... + + 7 — 1 1 1 1 Ancylostomiasis.- + + 7 — 2 1 2 2 Ascariasis ................... + + 7 — 2 1 2 2 Bilharziasis(schistosomiasis)- + + 7 — 2 1 2 2 Enterobiasis ................. + + —- — 3 2 2 2 Paragonimiasis. + -— — 2 1 2 2 Taeniesis .................... + 7 — 2 2 2 2 SECTION 4.—ASIA mus AND mcummn Smallpox .................... + + — + 3 2 1 1 Yellow fever- + i — i 3 3 2 1 Typhus ..... i + 2 2 l 2 Poliomyelitis .......... 7 - 7 1 2 1 2 Insect-borne encephalitis..-. + 1' - — 1 2 1 2 Dengue and other insect- + borne virus diseases ....... 7 7 —- — 1 2 1 2 7 — — — 1 2 1 2 _- + 7 + 7 1 2 1 2 Virus hepatitis. . ............ - 7 - - 1 2 1 2 Virus meningitis and other diseases due to enterovi- ruses ...................... 7 7 — — 1 3 1 2 Virus diseases of childhood: mumps, measles, rubella, chickenpox ................ + — 1 2 1 Influenza ............ + — 7 1 3 l 2 Adenovirus infections ....... 7 — 7 1 3 2 Other respiratory virus in- fections including common 7 7 — — 1 3 1 2 - - — — 1 3 1 2 + + + - 1 4 3 2 + 7 7 7 1 3 2 2 Qiever.- ........... .-.-.---- + 7 + — 1 3_ 1 2 32 UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE 1—A.——Infectious disease problems, by continent——Continued SECTION 4.—ASIA—Continued Disease Methods Cause of spread known under- stood Eifec- tive treat- ment known Effec- tive pre- Priority requirements for progress vention available (biologi- cal or Research chemi- cal) Socio- emmmh develop- ment Trained person- nel Finances VIE US AND RICKETTSIAL—OOD. Trachoma ___________________ Epidemic conjunctivitis in- cluding viral and bac- terial ...................... B ACTERIAL DISEASES Diphtheria __________________ Tetanus. _ Pertussis. .. ..__ Streptococcal infections. Staphylococcal infections. . Pneuminia .................. Acute and chronic bronchitis. Cerebrospinal fever .......... Cholera ......... Salmonellosis_. Shigeilosis ............. -. Entgritis due to Escherichia co .................... _ FUNGUS DISEASES Dermatomycoses ............ Histoplasmosis .............. VENEREAL GROUP OF INFECTIONS Venereal syphilis ............ Gonorrhea ................... Chancroid ................... Lymphogranuloma vene- reum ______________________ Granuloma inguinale ........ Nongonococcal urethritis and related conditions _________ Yaws ........................ Endemic syphilis and re- lated conditions ........... PROTOZOAL DISEASES Amebiasis ................... Leishmaniasis: Cutaneous ............... Visceral.-. .- Toxoplasmosis ............... nummmc DISEASES Ancylostomiasis ............. Ascariasis ................... Bfl‘gmziasis (Schistosomia- s ...... ' .................. Clonorchiasis. Paragonimiasis: ............. +++++++++++ ++++~++++++ ++ ++ +++++++ -e ++~+--+++ +~+++~++++I ’° | |++ + +++++++ ++ + + +++++2-~+I ++ w+ 'llw-aI-v row; |“""’i l“!"+++ +-e+—e>el «2| >44! ll“1 I““""’il lllllll D-IHD-IHb—Ih-ID-H-U-‘MH wmwwnwn—Hwnh um» w w an HH wwu w» NNNWNNN NM NNWNWWWi-‘NMW NNI—‘WMMNNNNN WI—I n m» on *»w “NM 03 MMNHHNH HH mmwuwwmwwfiw HHHHHHHHHHH HHH [O 03 N03 NW wane kONNMMMM ION) H HN [ON M1060 MN HHNHNNNNND—‘M MNHNNNNND—‘NH ION“ t0 NNNNMNN ION UNITED STATES AND WORLD HEALTH ORGANIZATION 33 TABLE 1—A.—-Infectious disease problems, by continent—Continued SECTION 4.—ASIA—Continued Disease Cause known Effec- tive pre- vention available (biologi- cal or chemi- cal) Efiec— tive treat- ment known Methods of spread under- stood Priority requirements for progress Socio- pnnnnmip develop- ment Trained person— nel Research Finances HELMINTHIC DISEASES—COD. ’l‘aeniasis ____________________ Liver fluke infestations ______ Hydatid ases ............ Trichinosis .................. Wuchereria infections (pro- ducing elephantiasis) ...... + ++++ ""lll’a N—e—ell v-I Hoar-N N “MNND 1—- Nun-to to western SECTION 5.—EUROPE VIRUS AND RICKE TTSIAL Smallpox ............ .- ...... yphus . . _ Poliomyali Insect-home encephalit - . . Dengue and other insect- borne virus diseases ....... Virus hepatitis .............. Virus meningitis and other diseases due to enterovi- ruses ...................... Virus diseases of childhood: Mumps, measles. rubella, chickenpox .............. .- Influenza ............ Adenovirus injections ....... Other respiratory virus in- fections including common Psittacosis- - - - Rabies- - - - BACTERIAL DISEASES Diphtheria __________________ Tet terms-- Pertussis ......... Streptococcal infec ions- Staphylococcal infections._ Pneumonia __________________ Acute and chronic bronchitis- Cerebrospinal fever .......... Salmonellosis-- . Shigellosis ____________ Enteritis due to Eschenc is co 1 ........................ Anthrax Brucellos1s Bacterial food poisoning. Leptospirosis ......... Listeriosis ........ Tuberculosis (anima _ ++++++ Tuberculosis- Leprosy. - Plague ---------------------- ++++++++++++ FUN GUS DISEASES Dermatomyooses ............ Histoplasmosis .............. ++++ +, (7) +++~ ++ ll+l 1~++ I‘ll w—el—c ww++ l+ll -.., l w-el ~4w+ +++--+++ 1~Ix~1~+++ +“+‘°“l |’°l """’l +~++++|++++1 +++++|1-~+| l l aw ll D-IHHb-I Duh-low M10091»: comb-ea» HMl-‘H :4th team» baton-mm CAD 5-4 HD—lh—I «new “0205 p-u-n-n-u-u—n lurk-#9026: “wwml-‘N wwwrcww thI-hwwth— HHHNmen—aw.‘ WleOpwat-‘Nw MNWNWWNNHW NNNHNNND—t-N NNNNNNNNNN i-‘HI-U-U-‘ODD—U—U—‘MWH wwwwmwwww» H an 95.1 ._. MN 34 UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE 1-A.—Infectious disease problems, by continent—Continued SECTION 5.—EUROPE—Contlnued Eflec- Priority requirements for progress Eflec- tive pre- Methods tive ventlon Disease Cause of spread treat- available Socio- ‘ known under- went (biologi- economic Trained stood known cal or Research develop- person- Finances chemi- ment nel cal) VENEREAL snow or INFECTIONS Endemic syphilis and re- lated conditions.-.. ...- + ? + — 2 1 2 1 Venereal syphilis + + + — 1 3 2 3 Gonorrhea... + + '1 — 1 4 3 2 Chancrold..- .. 7 + 7 f 1 4 3 2 Lymphogranuloma vene- reum ...................... + ? + ? 1 4 a 2 Granulorna inguinale ........ + ‘I + 'I 1 4 3 2 Nongonococcal urethrltis and related conditions ..... — — + - 1 4 3 PBOTOZOLL DISEASES Amebiasls ................... + + ? — 2 3 2 Leishmanlasis: Cutaneous ............. + + ? + 3 1 1 2 Visceral ______ + ‘I — 2 2 1 2 Toxoplasmosis ......... .... + — ‘2 — 1 3 1 2 HELMINT‘HIC DISEASES Ancylostomiasis ............. + + ? — 2 1 1 2 Ascariasis ................... + + ‘I — 2 1 2 2 Bilharzlasis (Schistoso- miesis). ___ + + 7 — 2 1 l 2 Enterobiasis- + + '1’ -— 3 2 2 2 Taeniasis.. .. + + ? — 2 2 2 2 Liver fluke infestations ...... + + -— — 2 1 3 2 Hydatid disease ............. + + —- ? 1 2 3 2 Trlchinosls .................. + + —- ‘P 1 2 3 2 The scientific outlook The outlook for further marked increases in world health is excellent, even though difficult problems must be solved. The Director General of the World Health Organization, Dr. Marcolino G. Candau, said in 1958: I am convinced that, if the great advances gained in science and technology are put at the service of all the people of the world, our children and their children will live in an age from which most of the diseases our grandparents and parents took for granted will be banished. It is in our power to narrow further the gap which exists between the few countries which have already reached a relatively high level of health and the many others which are still in the early stages of their health development. Through intensified and well-coordinated research we shall be able to find the means to cure or prevent the diseases which today prevail in the economically developed areas and which tomorrow may strike those regions which are in process of rapid development. Together with cardiovascular diseases, cancer, diabetes, arthritis, rheumatism influenza, poliomyelitis, etc., the treatment and the prevention of emotional and mental disorders are the great medical problems of tomorrow. We shall also have to face the consequences which the expanding use of nuclear energy may have for the health of man, and in this opening phase of the launching Of earth satellites it may no longer be utopian to envisage a new chapter in the history of medicine, linked to ways of traveling and of communication which have until now belonged to the realms of fantasy and fiction! 3 World Health. May-June 1958, vol. XI. No. 3, p. 5. UNITED STATES AND WORLD HEALTH ORGANIZATION 35 C. WORLD RESOURCES FOR HEALTH The world’s resources for health, broadly speaking, include the world’s capacity to produce food, clothing, and shelter, the educa- tional systems of the world, and the human institutions through which goods and services are distributed. But, here attention will be centered on health resources more nar~ rowly defined as the supply of physicians, nurses, dentists,‘technicians, and other specially trained people for health protection. The material resources for prevention and cure of disease, such as public health services, clinics, and hospitals, are also included. No country on earth has enough resources for health; every country is trying to expand its resources. This is the main fact. This explains why WHO, upon the urging of the member states, stresses (as shown in pt. III of this report) the training of manpower. The shortages of health resources in many parts of the world are appalling as indicated by figures for 1956, the last year for which data are available. For the whole of Africa, for example, there is only one physician for every 9,000 people as compared with one physi- — cian per 950 people in the United States. And, in many countries of Africa there are fewer than 1 physician for every 20,000 inhabitants. In Ethiopia, one doctor must serve 110,000 persons. In Indonesia, there is only 1 doctor for every 70,000 persons. The situation by continent is as follows: TABLE 1—B.—Number of physicians, by continent Area Population Number of Population physicians per physician Atrim 210, 832, 000 23, 284 9, 055 North and Central America ................................. 234, 276, 000 259, 664 902 South America. . 121, 000, 000 48, 263 2, 507 Asia, eastern 1, 370, 821. 000 209, 688 6, 537 Asia, western. 82, 529, 000 16, 951 4, 869 Europe.. . 619, 707, 000 665, 522 931 Oceania 14, 234, 000 12, 427 l, 145 World total... 2, 653, 399, 000 1, 235, 799 2, 147 The same wide disparity exists amon countries with respect to the size of the population groups that must e served by a single dentist or nurse. Diflerences in training Not only the supply of physicians, but the quality of training varies widely throughout the world. Medical and related education in many countries is deficient because of such factors, partly financial in origin, as inability to establish medical teaching as a full-time profes- sion, the inadequacy of classrooms, laboratories, and equipment, undéie reliance upon lectures, and failure to adjust curricula to local- nee s. Decades of work lie ahead in lifting the teaching standards of many nations in the fields of medicine, nursing, sanitary engineering, ' dentistry, and other related professions to the levels needed if people trained to protect health are to be available in adequate numbers. In many countries, new schools will have to be established. While national efforts will be most important, a substantial degree of inter- national collaboration will be necessary to strengthen the world’s structure of health manpower. 36 UNITED STATES AND WORLD HEALTH ORGANIZATION Disparity in hospital availability As might be expected, the physical facilities available for health protection are also unequall distributed over the surface of the earth. The extreme variations, and, particularly the virtual absence of health facilities in many densely populated areas of the globe, are seriously unfortunate. Curative medicine oflan effective scientific type must rest on good hospital facilities as its basis. Preventive medicine must depend in large measure on outpatient services for the ambulant case and on centers for health promotion through individual instruction in the principles of personal hygiene. Accurate data on the latter point—outpatient and health-center services‘are difficult to obtain on an international scale. In the provision of hospitals, however, the same deplorable disparity between facilities in various areas which has been emphasized in previous paragraphs is encountered. New Zealand and the United States have shown for recent years a ratio of close to 100 hospital beds per 10,000 population. In some Pacific areas reasonably satisfactory ratios are reported (61 in Malaya). The figure falls to less than 10 per 10,000 for many other regions (9 for Indonesia and 7 for Burma). In India and hianchuria it is esti— ' mated that about 3 beds are available per 10,000 population; and in China proper the ratio has been assumed to be about 1 per 10,000. Vast populations, then, are served by from one—tenth to one- hundredth of the proportion of hospital beds found in the most pros— perous areas. Everywhere the deficiency in medical personnel and institutional facilities falls most heavily on the rural population. States (in the United States) with less than 30 percent rural population have reported for recent years about 1,000 days of hospital care per 1,000 population per year; while for States with 70 percent or more rural population, the ratio has been about 500 days of hospital care per 1,000 popula- tion. Even in the most prosperous areas, it has been maintained that hospital facilities are not fully adequate. Studies in the United States suggest that the country needs 245,000 more general hospital beds, 325,000 more mental hospital beds, and 260,000 more beds for chronic diseases, which would bring the ideal ratio up to about 150 per 10,000. There are other trends of thought, however, which point toward more moderate goals. In Scandinavia, beds in tuberculosis sanita- ria are now being used for the care of the aged. In the Montefiore Hospital of New York City, a most promising program is in force under which patients are dischar ed from the hospital much earlier than has been the case in the past int are provided in their own homes with all necessary medical and nursing care under the general super- vision of the hospital staff. The magnitude of the task of providing even the most rudimentary health services for large parts of the world is staggering. The differ- ences in disease problems, in cultures, in material resources, and in social institutions are so vast that there is no single pattern or approach that will fit the world. This is why the World Health Organization, to whose activities this report now turns, stresses the prime importance of efforts to strengthen national health resources. This is a task that will endure for decades. An assessment of the first of these decaddes—the first 10 years of the World Health Organization—is in or er. Part II EVOLUTION OF WHO ACTIVITIES As the health problems of the world are viewed in relation to the resources of the world for health, several facts have become clear; (1) The world does not now possess, for the world as a whole, the resources to conquer all of its most urgent disease problems. (2) Advances in the state of the health of the world over the past decades have been little short of astounding. Further advances have a high degree of likelihood. (3) The economic capacity, the educational and research structures, and the scope and organization of health services vary in the widest de ee among nations. (4) A more e ective attack on the major diseases of mankind will rest to a large degree upon international efforts to strengthen the worldwide structure for health and to improve national health serv1ces. This part of the report is devoted to the role played by WHO as the primary agent of national governments in strengthening inter- national health programs. The first phase of this part reviews the main characteristics of WHO programs and recounts some experience gained in their eXecution. The second phase gives a few examples of the work carried out in some of the main fields of public health. A. THE CONSTITUTIONAL BASE The principles, objectives, and functions of WHO have“ been clearly stated in the preamble and articles I and II of its constitution: CONSTITUTION OF THE WORLD HEALTH ORGANIZATION The States Parties to this Constitution declare, in conformity with the Charter of the United Nations, that the following principles are basic to the happiness, harmonious relations and security of all peoples: Health is a state of complete physical, mental and social Well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the funda- mental rights of every human being without distinction of race, religion, political belief, economic or social condition. The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co—operation of individuals and States. The achievement of any State in the promotion and protection of health is of value to all. Unequal development in difi‘erent countries in the promotion of health and control of disease, especially communicable disease, is a common danger. Healthy development of the child is of . basic importance; the ability to live harmoniously in a changing total environment is essential to such development. The extension to all peoples of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health. Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people. Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. 37 38 ‘ UNITED sTATEs AND WORLD HEALTH ORGANIZATION Accepting these principles, and for the purpose of co-operation among them- selves and with others to promote and protect the health of all peoples, the Con- tracting Parties agree to the present Constitution and hereby establish the World Health Organization as a specialized agency Within the terms of Article 57 of the Charter of the United Nations. CHAPTER I. OBJECTIVE ARTICLE 1 The objective of the World Health Organization (hereinafter called the Organ- izatliolp) shall be the attainment by all peoples of the highest possible level of hea t . . CHAPTER II. FUNCTIONS ARTICLE 2 In order to achieve its objective, the functions Of the Organization shall be: (a) to act as the directing and co-ordinating authority on international health work; (b) to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, profes- sional groups and such other organizations as may be deemed appropriate; (c) to assist Governments, upon request, in strengthening health services; (d) to furnish appropriate technical assistance and, in emergencies, neces- sar aid upon the request or acceptance of Governments; (Je') to rovide or assist in providing, upon the request of the United Nations, liealth services and facilities to special groups such as the peoples of trust territories; (f) to establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services; (9) to stimulate and advance work to eradicate epidemic, endemic and other diseases; ( (h) to promote, in cO-operation with other specialized agencies where neces- sary, the prevention of accidental injuries; (1') to promote, in co-operation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; (j) to promote co-operation among scientific and professional groups which contribute to the advancement of health; (Is) to propose conventions, agreements and regulations, and make recom- mendations with respect to international health matters and to perform such duties as may be assigned thereby to the Organization and are consistent with its objective; (I) to promote maternal and child health and welfare and to foster the ability to live harmoniously in a changing total environment; (m) to foster activities in the field of mental health, especially those afl’ect- ing the harmony of human relations; (n) to promote and conduct research in the field of health; (a) to promote improved standards of teaching and training in the health, medical and related professions; (p) to study and report on, in co-operation with other specialized agencies where necessary, administrative and social techniques affecting public health and medical care from preventive and curative points of view, includ- ing hospital services and social security; (q) to provide information, counsel and assistance in the field of health; (r) to assist in developing an informed public opinion among all peoples on matters of health; (8) to establish and revise as necessary international nomenclatures of diseases, of causes of death and of public health practices; (t) to standardize diagnostic procedures as necessary; (u) to develop, establish and promote international standards with respect to food, biological, pharmaceutical and similar products; (v) generally to take all necessary action to attain the objective of the Organization.” UNITED STATES AND WORLD HEALTH -ORGANIZATION 39 Goals of WHO programs To achieve the broad aims defined by the constitution, the World Health Assemblies approve, year by year, long range plans and settle the broad lines of advance over considerable periods. The annual programs provide for immediate needs and the more urgent tasks. Within this framework the Organization has put into practice certain broad principles designed to further practical action in the field and to raise standards of health in all member countries. The fundamental object of the programs of WHO is to strengthen the public health services of countries which seek its assistance. The actual work is carried out, as will be shown, by the governments themselves. Three broad categories are now universally recognized; the preven- tion of disease by practical measures in the field and the laboratory; the promotion of mental, physical, and social well-being; and the care and rehabilitation of the sick. Experience has shown that in assisting countries, two steps are indispensable; the training of national medical and paramedical per- sonnel, and the strengthening of administrative machinery of health agencies at the national, provincial and local levels. In order to make international assistance to health projects more effective, WHO maintains close collaboration with the United Nations and its specialized agencies (see pt. V). At the local level especially, there is a strong movement toward concerted programs of community de— velopment. These general principles are put into efiect through two comple— mentary sets of activities. The first activity is designed to create a supranational health structure to meet those needs of governments which cannot be fulfilled by national efforts. The second activity is designed to strengthen the health work of national governments. B. FIRST OBJECTIVE—CREATE A WORLD FRAMEWORK FOR HEALTH The first function has been to create a permanent worldwide health .7 organization in which all countries are partners. This has involved a number of activities undertaken on a worldwide basis, and of interest to all nations: (a) Establishment of epidemiolo 'cal and statistical services on a world scale, from material 0 tained directly from every country. (6) Establishment of international standards of nomenclature, and the classification of diseases, injuries, and causes of death., (6) Standardization of pharmaceutical products and biological preparations. ((1) Collection and extension of knowledge of the theory and practice of public health work with a view to its international application. This is achieved by keeping in constant touch with diverse activities bearing on health, and assisting in the applica— tion of new developments in health services throughout the world. (6) Stimulation, promotion and coordination of research, dis- tributing widely its scientific discoveries and serving as a clear- inghouse for problems between one country and another. This past point is most im ortant and will be referred to in later pages in connection with deve opment of WHO research. 40 UNITED STATES AND WORLD HEALTH ORGANIZATION Considered as a Whole, these activities constitute a joint world health effort. The scale and degree of technical competence of the undertaking are unprecedented. C. SECOND OBJECTIVE—STRENGTHEN NATIONAL HEALTH STRUCTURES WHO’S general philosophy is that countries should be helped to gain a position that will make them largely self—reliant so far as health protection programs are concerned. If this objective is to be achieved, stress has to be placed on the establishment of strong, adaptable, well staffed, appropriately de- centralized national health administrations. To build such a struc- ture requires a substantial knowledge not only of medicine and public health but of modern administrative theory and practice. , Many nations do not at this time have the internal resources re- quired to build an effective public health structure. Accordingly, WHO advises governments on ways to strengthen existing national health services. Special emphasis is laid on coordinating programs and teamwork in the field. These joint programs include prevention and control of the main communicable diseases and professional and technical education of national health personnel. This includes the , _ provision of fellowships abroad on an extensive scale and plans for the training of auxiliary workers in the respective countries. Assistance to governments is given only upon their request. It is put into effect in the form of projects under the government’s own administrative control and within the scope of its resources. In fostering the self-reliance of individual countries, the Organization wisely seeks to insure the continuity of assisted programs after the period of international assistance has come to an end. In most countries in the early stages of developing a public health structure, the training of manpower is a matter of highest priority. In fact, the training of manpower is a problem that is so significant to all WHO activities that discussion of this subject is reserved for sub- sequent pages. D. EVOLUTION or FUNCTIONS The work of WHO during the past decade has gone through three distinct phases. First, there was the inevitable period of extemporization, required by the very novelty of international assistance. Then came an inter— mediate phase of experiment and ad hoc assistance. During this period, trial and error led to a better understanding of the value and the limitations of this form of international service. The experience ‘ thus gained paved the way to a third phase in which comprehensive assistance through teamwork has been the most striking characteristic. Programs have not evolved in isolation. They have been fitted into the general trend of socioeconomic and technical progress of countries requiring assistance. The existence of regional health organizations before WHO came into being has exerted a considerable influence on the structure and functions of the organization. As a result, regionalization is now a distinctive feature of the World Health Organization. Operations are highly decentralized to regions, and WHO’S relationships with governments on operating programs are conducted primarily through regions. The Assembly has defined six regional areas. UNITED STATES AND WORLD HEALTH ORGANIZATION 41 Fortunately, over the years there has been a constructive unity of effort between the Executive Board and the Director General, on the one hand, and the regional committees and the regional directors, on the other. The coordination between the Director General and the regional directors has been so close that it has been possible to adapt programs to the needs and circumstances Of assisted countries without unduly incurring the disadvantages which might be expected from a substantial degree of decentralization. Sequence of planning Plans of assistance to governments are preceded by systematic surveys. Detailed programs are made on the basis of these pilot studies. As time goes on, mobile campaigns become woven into more permanent services; simple projects become more comprehensive in scope and re ional work is broadened to include intercountry projects that extend ar beyond the regional boundaries. In the same way, a single fellowship award of a few years ago grew into a system of fellowships deliberately planned to meet the needs of a country as a whole and to create a sound basis for teamwork. The experience gained in assisting the promotion of single subjects in the medical curricula of assisted teaching institutions expanded as time went on. It evolved into a planned reorientation of entire curricula to suit the academic and practical needs of the countries concerned. As an accompaniment tO this broadening in the scope Of the Organ- ization’s work, there has been an encouraging improvement in the international climate in which various programs have been carried out. During the past decade the government and people of many countries have been made more aware of the importance Of reasonable health planning. It is evident from the records that there has been a growing acceptance by governments Of their new responsibilities and obligations in the promotion of health and the prevention Of sickness. . At first, all the concentration Of thought and finance was on the immediate urgencies of treating the sick and the relief of individual suffering. Longer range needs of international health work is now being more fully understood. It is receiving year by year increasing and understanding support by government, nongovernmental organ- izations, and other institutions. The emergence of the longer range view, as well as the emergence Of acute problems in disease control programs, has led to an increasing emphasis upon the stimulation, support and coordination of research by WHO. The development of the research function of WHO is, as previously indicated, a matter of such significance that it is dis— cussed in detail later (see pt. IV). E. OPERATING PROGRAMS—COMMUNICABLE DISEASES Carrying out the general functions of WHO involves the selection Of priorities so that the resources of the WHO and the member nations may be directed to important, attainable objectives. In its efforts during the past decade to attack the great epidemic and communicable diseases, WHO has concentrated its forces on improving resistance, 385l6—-’59t———-4 42 UNITED STATES AND WORLD HEALTH ORGANIZATION controlling the vectors, and reducing the animal and human reservoirs of infection. With this end in view it has sought to encourage research directed toward improving methods of control. This demands both surveys and active work in the field and fundamental research in the labora- tory. Progress in both is dependent upon the adequate training of personnel for both field and laboratory work. Training of auxiliary workers for research is particularly urgent. This in its turn demands that training courses should be organized for teachers. The training of instructors is probably best carried out by means of fellowships to established training institutions. However, the training courses for auxiliaries of all kinds must be carried out in the countries themselves. Coordination of research covering both the laboratory work and field studies is now being extended to a wide range of epidemiological problems. Epidemiological studies and local surveys have been recognized as essential to the preparation of projects against prac— tically all the communicable diseases. One of the difficult questions now under consideration is how campaigns against specific diseases can be combined in a general outline of communicable disease control and how they can be made part of the regular community health services in rural areas. As has been indicated above, an essential preliminary to this advance is the training of auxiliary workers both in individual subjects and in cooperation as a team. Malaria, Malaria is still the greatest single menace to the health of man and to his economic development. WHO has devoted more resources in terms of money and manpower to this than to any other disease. For this unprecedented worldwide attack on a single disease, the World Health Assembly has created a malaria eradication special account to which various nations, and notably the United States, have contributed very generously. Funds from the United Nations Children’s Fund and the expanded program of technical assistance of the United Nations are also being extensively used to implement the program. The eradication of malaria is indirectly but inescapably a matter of high significance to the United States. For this reason, the malaria program is described in some detail in the following part. Tuberculosis control The control of tuberculosis formerly required the building and maintenance of expensive institutions and the training of specialized stafi's. Both these requirements have surpassed the resources of many countries. In an effort to help them, the WHO in cooperation with UNICEF put into effect a worldwide program of tuberculin testing and BCG vaccination through which about 200 million have been tested and over 80 million vaccinated. A few countries have been assisted in setting up tuberculosis control training and demonstration centers. With antibiotics like streptomycin, and therapeutic drugs like isoniazid and PAS (para- amino-salicylic acid) it has been possible to secure effective home treatment of infectious patients and to attempt preventive treatment of recently infected contacts. As a result, health authorities in UNITED STATES AND WORLD HEALTH ORGANIZATION 43 many countries are anxious to determine the extent of their tuber— culosis problem so as to establish What is termed a base line. On its basis, they propose to plan effective programs adapted to their fiwn circumstances, and based on drug treatment in patients’ own omes. 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 sur- veys and control programs of tuberculosis. To this end, pilot projects in India, Tunisia, and elsewhere are being organized to discover the efl’ect 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 pro— tection of public health. As was pointed out above in relation to communicable disease control programs it is most important that the specialized pro ams be operated in relation to and eventually as a part of nationa 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 a sound national health structure. WHO alone could never hope to solve the overall problems of underdeveloped countries—— even those of health—unless it pursued its efforts in a concerted pro— gram 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 perma- nently insured. 44: UNITED STATES AND WORLD HEALTH ORGANIZATION 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 be- coming 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 na- tional 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 auxil- iaries 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 en- lightened program. The early type of joint UN ICEF—WHO maternal and child health project aimed at setting up a demonstration center in which inter- national experts trained their counterparts in the techniques of an te- natal, natal, and postnatal care of mothers and the care of infants, and in the management of “well baby” clinics. This concept has adually been amplified to meet existing needs and possibilities. ’ oday, maternal and child health work is often combined with .pro- grams 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 rehabili- tation 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 partici- pate. 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. UNITED STATES AND WORLD HEALTH ORGANIZATION 45 Nutrition Nutritional studies and projects, often supported by EPTA (ex- panded 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 im- proving 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 engi- neers. The World Health Organization is doing its utmost to encour- age’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 demon- stration 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 develop- ing 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 count projects in the few “pri- orities” of the First World Health Assem l 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 4.6 UNITED STATES AND WORLD HEALTH ORGANIZATION by the comprehensive project that assists a country to organize, for example, a mass campaign against a communicable disease, or pro- vides 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 epi- demiological 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, demon- strations, or seminars. There has been a significant and natural trend in the educational and teaching programs. The early single fellowship is now often re- placed by a s stem 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. Educa- tional meetings are more prominent in number and variety. Semi- nars, study groups, and conferences, as well as group training pro— grams such as courses, have become a feature of most technical pro- grams 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 phe- nomena 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 eflects if eradication is success- ful. The example chosen is malaria. Third, the eflorts 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 or 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 oflficials 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 48 UNITED STATES AND WORLD HEALTH ORGANIZATION Before recounting the story of the spread of the disease and of the operation of the worldwide warning established by WHO, five points should be made: (a) The 1957 influenza virus was not highly virulent. If it had been comparable in virulence to the 1918 influenza virus, the epidemic might have spread more rapidly. It might have attaclked more people and it would certainly have killed more peop e. (b) Since the influenza virus changes from year to year in unpredictable ways, there can be no assurance that a deadly flu virus will not appear in some year in the future. (6) Only because of the worldwide influenza warning network, including the effective work of the US. Army, did the United States have enough advance notice to prepare vaccine against the 1957 virus. . ' \j’, (d) Several weeks were. lost because the warning network did /W not include Communist China. A comparable delay in other years might make production of vaccine impossible. (e) The total annual cost to WHO of operating the early warn— ing system is less than $10,000 per year. Supplemental costs to WHO arising from the 1957 epidemic were less than $5,000. This amazingly low outlay arises from the standard WHO pattern of action involving stress on coordination and voluntary coopera- tion. All but a small fraction of the costs of operating the net- work are borne by the cooperating public and private laboratories. 2. HISTORY OF THE EPIDEMIC The virus was first detected in February 1957 in the Kwei-Chow province of China. From there it spread dramatically to all continents Within 6 months (chart 3—A). The sequence was, as follows—— Virus isolated in Peking in March (but this was not known outside China until later). By April-spread to Hong Kong and south to Singapore. Virus isolated in Singapore and Japan in May; virus identified and verified in Washington, London, and Melbourne by the end of May. All existing vaccines were by then known to be ineffective. In May and June, rapid spread to the Philippines, Japan, southeast Asia, and western Pacific. Then on to India, the Persian Gulf, Iran, Yemen, Egypt, and in other directions to Australia. Between June and August, widespread infection in the Southern Hemisphere and the Orient. Between June and August, the United States infected on both coasts in sporadic outbreaks as the epidemic spread in both directions around the world. Virus spread widely thoughout the country during the summer. Vaccine production begun. . fWidespread epidemics in the United States in the fall and winter 0 1957. The progress of the disease across the face of the earth was followed by scientists all over the world with unusual clarity, primarily because of the distinctive properties of the virus (the so-called A—2 type). Chart 3—A shows how the virus spread. The numbers on the chart correspond to months in 1957. Four phases were experienced in each country. 38516 O - 59 (Face p.48) CHART 3—A PROGRESS OF INFLUENZA EPIDEMIC FROM FEBRUARY 1957 T0 JANUARY 1958 Amsterdam Rotterdam The Hague I \ UNITED KINGDOM /\ ‘. Ve‘“ IRELANDg \ a é, n . L .-“‘ \ ‘ - Q facsiEcngs “we \ \ " . _’-/ (ii-«‘9’. at" ‘\\ . FRENCH WEST AFRICA ‘4' \ W LOVAKiA J I f v' J__,. V2.32 OMANLA 6; ‘v e‘ -._.__._¢ G) C D J / HA ' ’ /_\____‘9' 1,, Khartoum l,"”‘~ ‘ ADM“ , ', ‘ I . /’ \QDARFUR Diibouti NA TAL SYRIA" '/ 6,\. \~ _,'JORD \. / \__ \EQUATO'BIA 09mg,” ‘ @;\ Addis Ababa ~ \\ 6 TURKEY ,\‘/\ Baghdad \ a a \W ”a \ \\ \W \\\\W \\\\\\\\\\ \ W ® Probable origin of epidemic . First wave 0 First cases from May to August I Second wave The figures represent the months when the first cases / \0- ..... 9 ________ 9. _\ C 8 Harpon ‘\ QUEBE ‘ Z OWASHINGTON A e 9 /.\ 0 7 Argentia / \\\N\\\\\ J' ‘ é W \W \\ \ -" M d) ; 9 \W a 716W“ 0. K9 am“ \W Z © (/\‘ 0 “nne h V 6 \\\\\\\\\\\\\\\\\\\\\\\‘“\\\\\ Z 0??» - §® Cal un Co 0 8 Newport A-‘ —"~\‘ 'KObUI \_,_/f ¢W\\\V\\\\\\\\\\\\\xxxvua 1; § VGHOY Forge \, @Teheran ,I‘Gfi’aznie/ '> 7 \\\\\\\\\\\¢ § 8 N FarOHQ 6 If Lahore ‘I 9 Tokyo g ' Q E LOUISIANA Offolk d‘aAbadan ‘\ [J 6/ '\l‘ 9 % \\\\“‘\\\\\\ S Diego \"—'\ TEXAS 09 8 “" 1' K \‘ o / \\\\\‘\\\\\\\\ V‘ /\ 7 BAHREIN \, Karachi Q “-l‘Fik-"P? 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Valparaiso [’9 YMendoza 8 Buenos Aires Adelaide 5 VICTORIA 7 Sydney E: /_, TASMAN/AW Wellington WWW WHO 8186 UNITED STATES AND WORLD HEALTH ORGANIZATION 49 Introduction of the virus The virus was spread by human contact. Seaborne traffic was more important than air travel. Thus Cairo, a key center for air travel from the East, did not have an epidemic earlier than ad'acent coun- tries. Ships undoubtedly were concerned in the arrivai of virus in the Netherlands and possibly on the east and west coasts of the United States of America. Air travel played a part, but the relative iinportance of air travel was at times impossible to assess. In the case of continental land masses, such as China and the U.S.S.R., the spread occurred in relation to railways such as the Trans-Siberian railway. Although the chart does not indicate details, a clear chronological sequence of outbreaks from east to west across the route of the Trans-Siberian railroad has been traced. In Israel, where the epidemic occurred some weeks after the outbreaks in ad- jacent states, it seems likely that lack of direct traffic to and from these areas was responsible for the delay. It was during this phase of the epidemic that the WHO warning network was particularly active. The entire world was tied together in an intelligence network which permitted each country to know where the disease was striking, and even to be able to predict weeks in advance when the disease would arrive. This ability to anticipate the arrival of the disease was the factor that permitted the United States to have a vaccine ready in time. Virus ”seeding” In many tropical countries and also in Japan, once the virus was introduced there appeared to be an immediate spread of infection accompanied by a rapid buildup of outbreaks into a general epidemic. But in other countries and particularly in Europe and the United States six or more weeks’ delay occurred after the first detected entry of Virus before a general outbreak involved large sections of the population. During this delay the Virus was being spread throughout the popu- lation. This process was sometimes silent, sometimes accompanied by local outbreaks, and sometimes detected by a chain of infection. In the United States as well as in other countries, dispersion of travelers from conferences, scout jamborees or youth festivals assisted the spread of virus. The factors chiefly determining the length of this preepidemic phase are not known. Climate, social customs, and the state of the schools appeared to be important. It is also possible that the virus was not always detected when first introduced. Schools were closed for holi- days in many countries where a lag was experienced, and the general epidemic coincided with, or quickly followed, their opening. Ability to predict when the widely spread virus will erupt into an epidemic is important because of such practical purposes as planning for the use of medical care facilities. Research on this aspect of influenza is, therefore, clearly important. . The main epidemic phase In all countries the patterns of sickness of the general epidemics were remarkably similar. Attack rates were high, outbreaks were frequently explosive but there were few deaths. School-age children 50 - UNITED STATES AND WORLD HEALTH ORGANIZATION were heavily attacked and adults, particularly those aged 40 or more, were relatively spared. Mortality, however, increased with age. In some countries—Chile and the Philippines, for example—there was a high mortality also among infants. The pattern of mortality in England and Wales showed a greater proportion of deaths in the younger population in the first four com- pared with the subsequent weeks of the epidemic. This appeared to be a reflection of the adual extension of infection from the children to adults. Particular y high attack rates with explosive epidemics were seen in military establishments and residential schools. It was not possible to determine the precise reasons for the variation in the attack rates nor to discern details of the mode of spread of the virus. Close contact, crowding of persons together, particularly in dormi— tories or barracks, appeared to favor, and dispersion to limit, the spread of infection. Here again, it should be noted, research is re- quired. Knowledge of the factors responsible for spread may be used to reduce the attack rate, or to spread cases over a longer period, thus reducing the strain on medical care facilities. The postepidemic phase In many countries the main epidemic phase was succeeded by a state of apparent quiescence of infection. Nevertheless the Asian virus continued to be isolated month after month. A definite return of clinical influenza occurred in the Netherlands in January to May 1958, 2 months after the end of the main epidemic. In the United States and also in Britain a second milder epidemic apparently oc— curred 3 or more months after the general epidemic. In Japan, in India and in certain areas of the USSR. definite epidemics of in- fluenza with a high morbidity developed 5 or 6 months after the first epidemic; these were due to the same Asian virus. The geographical areas attacked in Japan and in the U.S.S.R., during this second out- break of infection were often those lightly involved in the first epi- demic. There was evidence also that most persons who suffered from influenza in the first epidemic escaped during the second outbreak. The precise reasons for the varied experience of different countries during the postepidemic phase could not be ascertained. In total the experiences of the 1957 pandemic of influenza show the need for further research. The factors Which determine the speed of spread of infection are still obscure and can only be determined by further observations combined with laboratory studies. Until more research is done it is probable that the spread of infection cannot be stopped except by a limitation of human contacts. 3. THE WHO INFLUENZA PROGRAM Cooperation among the 56 laboratories in many different countries working under the WHO influenza program was a striking example of the effectiveness of international cooperation (chart 3—3). This collaboration with the WHO’S World Influenza Center in London and the International Influenza Center for the Americas contributed much to knowledge of influenza and means of controlling it. Chart 3—B shOWs the network of 56 influenza centers. This is an operating system of worldwide scope which is not only an intelligence network but also a means of tying together the major influenza research centers of the world. CHART 3—B WORLD INFLUENZA CENTRES AS AT MARCH I958 . buulkul Cm..- .Cuwu .05....“ NOILVZINVD'HO HL’IVMH G'IHOAA CLNIV SEICLVLS CEILING. IQ 52 UNITED STATES AND WORLD HEALTH ORGANIZATION There is general agreement among experts that the world was fortunate in having a mild worldwide influenza outbreak to test the early warning network. It did not work perfectly. The action required to make the system even more effective was clearly indicated. For example, some reports of epidemics to WHO and the dispatch Of virus strains to the international centers were delayed or neglected altogether, even when there were signs that an epidemic or unusual strain or virus had appeared. More effective operation of the existing network is clearly called for. As another example, many countries and territories, even those with the necessary laboratories have not named such a laboratory to be Officially responsible for cooperating in what must be truly a world- wide program if it is to be effective. Recall, as noted above that the recent pandemic began on the Chinese mainland, an area not covered by the WHO program, and that as a consequence there was a 2- month delay in learning of the new virus. Once news of the unusual epidemic was received by the US. Army and the WHO influenza center laboratories the warning system worked well. The virus was isolated, sent to the appropriate refer- ence center and identified as an entirely new strain Within 3 weeks, and the information being broadcast to the rest of the world immedi— ately. This was a notable achievement. However, it cannot be stressed too Often that if the information had been received promptly from China, the rest of the world would have had 2 more months in which to prepare. Clearly every country, with the necessary laboratories, should cooperate in this, program, and efl’orts should be made to establish laboratories where they do not now exist. 4. INTERRELATIONSHIPS OF RESEARCH AND DISEASE CONTROL The WHO influenza program is an instructive example Of the way in which research and practical public health measures are inter- twined. The program was started by WHO in 1947 primarily as a research project to - learn more about the epidemiology of influenza. The laboratory network is now, as has been pointed out above, an essential part of the worldwide public health defense against influenza. The original research laboratory network now Operates in close relationship with national public health authorities. This is necessary so that the influenza centers can know of, be informed of, and promptly initiate studies of, outbreaks in remote areas. They thus may keep health authorities informed of the appearance of unusual epidemics through- out the world and of the appropriate technical countermeasures. So far as influenza is concerned, the 1957 worldwide epidemic was the first to occur since modern methods for study of the virus became available. A number of studies have therefore been planned and are being coordinated by WHO in the hope Of learning more of the epi— demiology and prospects of control of influenza. For example the WHO Influenza Center in the Netherlands dis- covered in June that antibodies to the new virus were present in some persons of over 70. WHO was immediately informed, with the result that it was possible to arrange the collection of sera from elderly per- sons in some other areas not yet involved in the epidemic. The UNITED STATES AND WORLD HEALTH ORGANIZATION 53 studies have confirmed the Dutch findings, a result which would have been impossible if collection of the sera had been delayed until the epidemic had reached the area. This discovery may prove to be of great importance since a possible interpretation is that the new virus is related to the .virus responsible for the 1889—90 pandemic. There is a possibility that certain domestic animals, particularly swine, may play a role in the e idemiology Of human influenza. Arrangements were therefore made y WHO to collect sera from swine ‘ and other domestic animals in 25 countries in different parts of the world before the epidemic reached them. Later, after the epidemic had passed, further sera were collected from the same animals and the two are being compared for antibodies against the Asian strain. On a broader scale, it is now becoming clear that the influenza centers, which were necessarily virus laboratores, form a natural nucleus from which WHO may help to evolve more extensive virus studies on a worldwide basis. B. MALARIA ERADICATION A decade ago, about 3 million people a year died from malaria. About another 300 million suffered the weakening effects of malaria. Despite the high figure Of annual deaths, and though it is often a major cause of infant mortality, malaria is important mainly because it produces chronic invalidism. It is insidious rather than dramatic except when, for reasons imperfectly understood until recently, epidemics flare up, as in Ceylon in 1934—35 or in Brazil in 1938—39. It leads to an increased number of deaths from other causes, impairs physical and mental development, and affects birth rates and the survival of newborn. It has serious repercussions on agriculture, commerce, and industry. Wherever it exists, human progress is retarded or inhibited. The development of many potentially fertile areas of the world is barred by its presence. Other areas, in which human activities have encouraged the breeding of the mosquito vectors of malaria, have been developed and later abandoned. The disease was, and has been from time immemorial, one of the major health problems of mankind. But little could be done except to suppress the symptoms of the disease through use of quinine. Economic toll Malaria is an expensive visitor in any country. In 1909 it was estimated that malaria was costing the United States $100 million a year. By 1938 these annual costs had risen to $500 million. In an epidemic of malaria in southern Egypt in 1942 to 1943, one plantation alone suffered a monetary loss equivalent to $600,000. A petroleum company in Venezuela estimated that malaria cost the company $494,500 over a 6—year period due to personnel illness attributed to the disease. Even with the eradication of malaria from the United States in 1945—48, it still levies an enormous hidden tax on the people because imports such as basic minerals, hardwoods, coffee, cocoa, vegetable oils, waxes, and certain fruits which come from the malarious Tropics are priced at least 5 percent higher than they would need be if it were not for the cost of malaria. 54 UNITED STATES AND WORLD HEALTH ORGANIZATION In India the estimated 25 percent decrease in the working capacity of labor in the malarious areas produces an estimated annual loss of about $450 million to the economy of that country. 1. THE TWO TECHNICAL ADVANCES Two technological breakthroughs completely altered the world out— look. DDT was developed, and this opened the possibility of stop- ping malaria by massive killing off of the mosquitos which spread the disease. Second, drugs which kill in the victims’ body the parasite responsible for the disease Were developed. The disease could be cured, rather than its effects suppressed. The two technical advances presented a series of strategic questions to WHO. Were the technical advances such as to warrant an effort to rid the world of malaria? Was malaria a disease of such signifi- cance that it would rank high on a priority list of threats to the health of the world? Should reliance be placed on curing individuals through mass treatment campaigns, or on breaking the chain of infection by killing off the anopheline mosquitos which carry the disease? 2. EARLY STRATEGIC DECISIONS There was no doubt as to the seriousness of the disease, but the approach to be used presented difficult problems. . Controlled experiments in the use of two new antimalarial drugs, chloroquine (aralen) and proguanil (paludrine) were proposed, but -WHO placed its faith in the use of DDT a ainst adult mosquitoes as the main instrument for malaria control. he decision was made not only on grounds of efficiency, but also for economic reasons. Malaria, poverty, low population density, and lack of development are insep- arable in the rural tropics. The administration of antimalarial drugs, at least weekly, would demand organization that does not exist and could not be set 11 in most of the affected areas. Prevention of mosquito breeding by attackin the larval forms in water becomes more expensive per person the lower the human population density. In contrast, the use of DDT as a house spray, once or twice a year, demands a comparatively small, mobile organization. Its cost, Which depends on the number of houses to be sprayed, remains about the same per head whatever the population density, except in rare circumstances. Other chemicals, notably benzene hexachloride (BHC) and dieldrin, have been developed, supplementing, not replacing, DDT. Diffi- culties, foreseen and unforeseen, have had to be overcome, but WHO’S original policy of relying on residual insecticides for world malaria control has never been superseded” 3. OPERATIONAL PROCEDURES 1 With some of the basic questions settled, difficult operational prob- lems had to be solved. In 1947 and 1948, these principles were as follows: (1) Demonstration teams Were to visit any malarious country requesting assistance. The basic composition of a team was a malariologist and an entomologist, with the addition of a sani- tarian or a sanitary engineer. UNITED STATES AND WORLD HEALTH ORGANIZATION 55 (2) With a view to creating local malaria organizations, the expert committee recommended that governments should ap— point nationals to understudy each memberof the international team. , (3) At the same time, it was recommended that WHO should provide expert lecturers for existing schools of malariology, assist in setting up courses in malariology in regions not yet provided with such facilities, provide fellowships for individual training abroad, and circulate literature both on technical subjects and on the health education of the ublic. Here, in concrete terms, is an example of the way in W ich extension of disease control programs depend on the training of people. The program expanded satisfactorily. Seven teams were operating by the end of 1949, all in Asia—four in different provinces of India, one in Afghanistan, one in Pakistan, and one in Thailand. Prepara— tions for an eighth, in Iran, were underway. Expansion of activities continued smoothly in 1950, by the end of which year nine demon- station teams were at work. Those previously established had ex- panded their areas of operation, and in India and Pakistan during 1950 the number of persons protected from malaria was increased fourfold. In the demonstration areas of Thailand and Pakistan, and in at least one area of India, there was evidence that the transmission of malaria had actually been interrupted. 4. A REVOLUTIONARY DEVELOPMENT At about this time, two events occurred which completely changed the world strategy for dealing with malaria. The first development, a favorable one, related to the technique of DDT spraying. Greece, which had converted its malaria-control program (begun with assistance from the Rockefeller Foundation) into a nationwide DDT spraying campaign since 1946, found diffi- culty in procuring the DDT necessary to maintain coverage over the whole area. It was decided, instead of reducing the dosage in all areas, to continue spraying in some areas, but to discontinue it al- to ether in others. he results proved that discontinuance of spraying in such circum- stances did not result in a recrudescence of malaria, although some cases did occur. The local malaria service established a special organ- ization of “epidemiological surveillance.” This picked up cases easily enough, evidently before they infected enough mosquitos for the disease to become widespread again. This accidental discovery had tremendous implications. It now seemed feasible to eradicate malaria by programs limited in time. This in turn meant that countries which could not afford a continuing program could consider an all-out effort for a limited period. 5. MEANING OF MALARIA ERADICATION Here the meaning of “malaria eradication” and other terms must be spelled out to permit an understanding of later WHO programs. Malaria eradication means the ending of the transmission of malaria and the elimination of the reservoir of infective cases in a campaign ‘ limited in time. This must be distinguished clearly from two other concepts. 56 UNITED STATES AND WORLD HEALTH ORGANIZATION Malaria control, until recently the sole aim of campaigns in most countries, implies the reduction of the disease until it is no longer a major public-health problem. Control must be maintained by continuous active work. The program is therefore unending. “Vector eradication” means the total elimination of all members of the mosquito species carrying the disease, so that they do not breed when the program is ended. It is therefore a roject limited in time. It is feasible, and has been achieved, in some places, but is not practi— cable everywhere. “Malaria eradication” is the application of the same principle, not to the mosquito but to the malaria parasite, and has been shown already to be applicable in many countries. As generally used, the term does not imply that vector eradication is necessarily to be achieved too. Malaria dies out in infected individuals within 3 years; the aim of eradication is to break the cycle of transmission for 3 years, so that thereafter antimosquito measures can be discontinued, leaving the mosquitos in existence but without the possibility of becoming infected. , 6. INSECT RESISTANCE A second development was ominous—resistance to insecticides. As early as 1947, it was found in Greece that the housefly and a kind of house mosquito (Culex molestus) had become resistant to DDT. In 1951, our troops in Korea were threatened by the development of resistance to DDT in body lice. Thereafter resistance developed rapidly all over the world, and disease-carrying insects in many areas became resistant not only to DDT but also to newer and more potent insecticides. By 1955, the number of new species of insects reported as resistant was 37. This phenomenon is the result of genetic selection (“the survival of the fittest”). Insects thus capable of withstanding the insecticides, created a worldwide problem. Not only the malaria program, but the effectiveness of insecticides in agriculture, were threatened. 7. RESPONSE—ERADICATION The response of WHO to the favorable and the unfavorable develop— ments was twofold. ‘ ' First, a new and more extensive malaria eradication program was mapped out. Eradication might have remained an exceptional aim if the development of resistance had not made it probable that mere control by spraying over extended periods would be futile. The experience in Greece demonstrated that an eradication campaign would call for the provision of special finance for a limited time only. This represented a necessity more easily understood by the local people and their legislative representatives than indefinitely continued expenditure on malaria control. Eradication, previously regarded as an ideal in favorable circum- stances, had therefore now become a matter of urgency. The cycle of transmission had to be broken before insecticide resistance developed more widely. Aware of the increasing danger of resistance in the arancsingttmg mosquitoes, the Eighth World Health Assembly in 1955 cm e —— UNITED STATES AND WORLD HEALTH ORGANIZATION 57 that the World Health Organization should take the initiative, provide technical advice, and encourage research and coordination of resources in the implementa- tion of a program having as its ultimate objective the worldwide eradication of malaria. ‘ The same resolution authorized the Director General _to obtain financial contributions and to establlsh a malaria eradicatlon special account. New requirements New techniques had to be developed for the new program. A malaria eradication program differs radically from mere control in a number of ways. The standard of execution must be perfect, and must be checked by constant surveillance of the population for fresh cases. The source of any case must be investigated, and any spread from that source prevented. As the campaign approaches its goal, the detection of residual foci of transmission becomes more important. This may be difficult as many foci are likely to display themselves only through the movement of residents, to appear as malaria cases in areas supposedly cleared of the disease. The source of the infection must_be sought. It may turn out to be overlooked hamlets or possibly a group of regular migrants. Whatever the mechanism of an eradication campaign, its task is accomplished when the evidence of surveillance and a methodical search for cases indicate that transmission is interrupted and that the number of potentially infective carriers is reduced, if not to zero at least to an insignificant level. The active campaign is then dis- continued. But it is the essence of a successful eradication campaign that it must include a maintenance organization efficient enough to recognize reintroduction at the earliest possible moment. It is to be assumed that the apparent elimination may not be perfect, and that immigrants or infected mosquitoes from outside the country may reintroduce the disease. The most likely source is an immigrant or a person with long— standing symptomless mfection, who will therefore not be detected as a case but will infect a certain number of anophelines. The appear— ance of even one such case must be the signal for an immediate inten— sive search for other cases, and also for a temporary and local anti- mosquito campaign. The number of secondary cases arising from this source will be fairly small, but being nonimmunes they will become highly infective to mosquitoes. Malaria is then transmitted with increasing frequency until an obvious epidemic results. 8. THE RESEARCH RESPONSE The conversion of malaria control programs into the aim of global malaria eradication with its much more demanding criteria showed gaps in knowledge. It necessitated the study of a series of important problems not by routine surveys but by special field and laboratory investigations carried out by experienced research workers. The new problems are typical of the manner in which a disease control program generates problems requiring research for solution. It comprised the following subjects: ' ((1) Behavior characteristics (including biting‘activity and host preferences) of several anopheline vectors. 38516~59——5 58 UNITED STATES AND WORLD HEALTH ORGANIZATION (b) Phenomena of resistance of anopheline vectors to residual , insecticides. Biochemistry and genetics. (0) Drug resistance of malaria parasites. (d) Host-parasite relationship in highly endemic areas. (6) Improvement of insecticide formulations and of spraying equipment. A vast amount of research work on these subjects was carried out by the WHO staff and by national personnel stimulated, assisted, and coordinated by the Organization. Finances for research were not immediately available. Our own Public Health Service was fortu- nately in a position to be of particular service. The results showed once again that ever malaria-eradication pro— gram must be carefully adjusted to the localiconditions prevailing and that hard—and-fast rules are not applicable in dealing with a community disease which has so many facets. The knowledge thus obtained permitted adaptation of resources to specific needs, saved many disappointments, and corrected many mis— takes. Thus, for instance, in areas Where the local anopheline was found sheltering in cattle sheds the extension of residual spraying to these outhouses became necessary. Where mud walls had a highly sorptive action on insecticide emulsions a different formulation con- sisting of a water-dispersible powder was used. Where the local population led a nomadic life antimalarial drugs had to supplement and often to replace the residual insecticides. Finally, where the resistance of the local vector was confined to one insecticide, another insecticide could solve the problem. As is the ‘case in all the research work coordinated by WHO, the Organization actually pays or can pay out of its own meager budget for very little of the malaria research work done at its request or on its behalf. It receives without much cost the invaluable assistance and advice of institutions, laboratories, and individuals. The full extent of these cooperative relationships is outlined in part V. In malaria research, there were ample dividends of benefits to our Public Health Service, both directly and indirectly, in terms of possible applicability of ,findings to other research problems, for example. Generally, research problems have been approached through both laboratory and WHO field research. (a) Laboratory research WHO has established close relations with some 40 institutions and laboratories throughout the world. They collaborate with the Organization and undertake, on its behalf, a considerable volume of basic or laboratory research in malaria. Although small subventions or grants-in-aid are paid to several of these institutions, most of them undertake research in the field of malaria at the request of WHO with— out eost to the Organization. In'addition there are some 120 laboratories and individuals in var- ious parts of the world working in close cooperation with the Organiza- tion on the resistance of insects to insecticides, including the problem of resistance in anophelines. Only six of these institutions receive any financial aid from WHO. I UNITED STATES AND WORLD HEALTH ORGANIZATION 59 The levels of financial assistance given in recent years and planned for 1959 to institutions and laboratories collaborating with WHO in this field'are as follows: 1956 ____________________________________________________________ $5, 000 1957 ____________________________________________________________ 34, 000 1958 ____________________________________________________________ 52, 000 1959- .; _________________________________________________________ 61, 000 (1)) Field research _ Every plan of malaria eradication must be based on a detailed survey of the conditions of the area involved, to determine the strategy of future action. This is necessary because the local features of malaria vary considerably in"re1ation to the parasite species, its mosquito vector'and'the physical,'biologica1'and also socioeconomic environ- ment. ” These preliminary surveys of every malaria campaign and the followup assessments of its results have comprised most of the malaria field research. The studies have required teams with specialists trained in such disciplines as systematic entomology, parasitology, geographical pathology and vital statistics. The need of field research will be recognized when we take into account that the difference in the habits of mosquitos affects the spread of malaria. With a mosquito which prefers human blood (like A. gambiae in Africa) malaria saturates the community, because few mosquitos are required to infect an entire population, and is stable from year to year and difficult to eliminate. With a mosquito which prefers animal blood (like A. culic’ifacies in India), the maintenance of malaria de— pends on the existence of a large mosquito population. In the latter case any antimosquito measure which is applied may be sufficient to reduce the number of mosquitos to the point Where malaria will die out. 9. IMPRESSIVE RESULTS Has the eradication campaign been a success to date? The answer is that there has never been such a successful attack upon a disease of worldwide importance through a planned inter- national efiort (chart 3—C). One of the most remarkable improve- ments in the worldhealth situation has been due to thewidespread control of malaria. Out of the world’s total 1958 population of 2,737 million, about 1,163 millions live in areas where malaria is still, or has recently been, endemic. In 1957 the protected population amounted to 454 million. Today’s figures of prevalence and mortality are approximately half what they were 12 years ago: the present number of deaths stands at 1% million and the total cases about 150 million. In practically all the countries Where malaria still constitutes a public health problem, programs of control are now being carried out; indeed, in regions other than Africa most countries have intro- duced nationwide programs. In six countries of Asia—Afghanistan, Burma, Ceylon, India, Indonesia, and Thailand—~recent estimates indicate that control programs have already protected 121 million people out of 250 million living in malarious areas. Pilot projects CHART 3—0 \ K / WW 3 :sn‘rus or MALARIA ERADICATION IN THE WORLD AT A - .d) s H \ETAT DE L' {RADICATION DUW PALUDISME DANS LE MONDE A LA FIIN DE I957 ' TUACION DE LA “<23 finumbfln‘clx “want—”Hm“ .I‘mhl-llll-lflr-Hlflulyklhh Klan-unwind.) €27 -.Iwu~&.wmI—-.W *kmwnmkwwmhw‘“ luv-r—I'HI-n-hpl-lh-«nanl'mul- mid-“humanly“ "ml‘whfldl—Hu-J‘hflmh wrumkfih-fl-fi-k -._..,_awu-u.'.u.«»u.-uunn Elm-Ha...»— EMM‘“ --..._a..uu¢u-—anaumlh u-IH-Idohu—l—IIIUI-Hh Miflfl-vlfl-uum—wflfim Dun-Mm m nu NOICLVZINIVD'HOA HJIIVEIH G'IHOAA (INV SHLVLS CELINE 09 UNITED STATES AND WORLD HEALTH ORGANIZATION 61 have been started in a few countries and territories of Africa, includ— ing French West Africa, French Cameroons, Liberia, Nigeria, and Tanganyika. The main Object of these programs is to collect infor- mation for planning large-scale antimalaria programs. In some in- stances a fresh approach has had to be made because in certain dis- tricts anopheline mosquitoes are developing resistance to insecticides. Nevertheless, practically complete eradication of the disease has been secured in British and French Guiana, Italy, the United States, Argentina, Ceylon, Thailand, and Venezuela. In many Of the re- maining parts of the world eradication work has been started and the disease has become insignificant as a health problem. This success does not mean that all problems are solved: 1. The campaign will lag, with the possibliity Of losing ground already gained unless funds for a more intensive effort are forth- coming from the member nations of WHO. The United States has done its full share in financing this ground-breaking health campaign. 2. Malaria eradication is extremely difficult in some areas. It may be impossible in some parts Of Africa. But 20 years a O a proposal for malaria eradication in any part Of the world wou d have been considered silly. In any event, some countries have not yet committed their resources, however inadequate, to the task, and serious administrative deficiencies remain in many countries. 3. As more and more countries achieve malaria eradication without vector extermination, the continued existence of malaria in other countries will become of increasing international im— portance: while the parasite exists, no country with potential vectors can forget the possibility of its importation. 4. Economic gains have been seen in practice to follow malaria eradication. However, another observed result is rapid growth Of population. Responsible sources have expressed the fear that food supplies may not increase in proportion. While endemic malaria is itself one of the great causes of low agricultural pro- ductivity, it is realized that this possibility cannot be ignored. Therefore, a malaria eradication campaign should be seen as part Of a general program Of development and social advance. It must, in sum, be an integral part of overall national planning efforts. 0. EDUCATION AND TRAINING Every major disease control program needs more trained people. As has been pointed out in part 1, every country suffers—some to an alarming degree from shortages of doctors, nurses, midwives, sanitary engineers, and technicians. Shortages of well-trained scientists set an absolute upper limit upon the rate at which research in many fields can advance. Gradually, the training Of manpower has been forced to thelfore- ground as a major prerequisite to the attainment of virtually all of the Objectives of WHO. There is no quick way to solve the manpower problem. The human and material resources required for training programs cannot be pro- duced in short order. It takes many years to train health workers of professional status, and they must first have had an adequate pre- ’ 62 UNITED STATES AND WORLD HEALTH ORGANIZATION liminary education. Moreover, with the continuing trend toward specialization, it is necessary (in addition to the general training of doctors and nurses) to train public health doctors, pediatricians, bacteriologists, nurse midwives, public health nurses, etc. Of all the resources necessary for the provision of training, well—qualified teachers are the scarcest and they take the longest to train. The approaches to solution of the manpower problem differ in ac- cordance not only with the activity for which training is given, but also in accordance with specific local needs. Moreover,- the solution of the problems of individual nations should, to be consistent with WHO’S general approach, be designed to strengthen nations’ abilities to train their own people. This means that attention should be paid not only to individuals, and to the health professions, but also to the educational institutions which train and educate people. In short, the manpower problem is one of the most critical and most complex faced by WHO and the member nations. While the variations in detail among training programs areextreme, general objectives of some of the major ones can be presented. _ 1. PROVIDE TECHNICAL SKILL BY FELLOWSHIPS A major objective of the WHO training and education program is to help countries to obtain technical skill and knowledge that they now lack. Except for what can be learned by self-tuition or from publications, there are only two ways of bringing new knowledge to a country; either somebody goes abroad to learn, or somebody from abroad comes to teach. WHO fellowships are a meansrof send— ~ ing people abroad; provision of visiting professors and related devices are a means of bringing people from abroad to teach. They will be briefly explained in that order. During the first 10 years of the WHO fellowship program (1947—56), 6,396 awards were made, not counting travel grants for educational meetings organized by WHO or for such purposes as the exchange of research workers. As of December 1958, almost 8,000 awards had been made. With this increase in total numbers in mind, atten- tion will be centered on the 1947—56 period because it marks a decade « of experience and because the effects of the program were assessed over that period. Experience in the 2 succeeding years has followed the pattern of the first decade. Beyond any doubt, these 8,000 fellowships have greatly extended the world’s capacity to improve the world’s health. Qualifications of candidates / First, the candidates were well qualified for the tasks they were ‘ trained for. The fellows were usually doctors or graduates in medicine ‘\ holding other diplomas (65 percent). But there were also graduate nurses (12 percent) sanitary engineers and sanitarians (6 percent) and other qualified health workers (17 percent). There were some fellowships (4 percent) awarded for undergraduate studies abroad, basic professional education not being available in the country of origin. Most of the fellows had substantial experience in the subject they wished to study further abroad; the average age of all feIIOWS, including undergraduates, was 40 years. Most of the fellowships went to personnel of national and local health services. But about one-tenth were granted to academic personnel such as deans, UNITED STATES AND WORLD HEALTH ORGANIZATION 63 principals, professors, and other teaching staff of university faculties and schools Of public health (this proportion was higher in some countries). Some were granted to personnel of research institutions. A quarter of the fellows were women. Diversity of study Second, the fields of study have been distributed in accordance With the primary needs of countries. The subjects studied have fallen into three major groups: health services (59 percent), control of com— municable diseases (28 percent), and medical education, clinical and basic medical sciences (13 percent). The distribution of subjects of study by country of origin of the fellow is determined by the needs of the country itself, its own plans in health, and the type of projects assisted by WHO. But it is also influenced by the number and type of health personnel available for advanced studies abroad. The distribution of subjects studied has changed gradually. The change in the subjects studied has been mainly an increase in the proportion of fellowships for studies in subjects‘that may be grouped under the general heading of health services (from 39 percent in 1947 to 65 percent in 1956). The proportion for clinical studies has shown the heaviest reduction (from 39 percent in 1947 to 14 percent in 1956). Followthroagh , Third, the fellows have contributed to the health programs of these countries upon return. Of all former fellows, 94 percent are occupied in a specific health task. About 40 percent of them were given greater responsibility upon return. In addition, fellows bring back new ideas and techniques which they pass on to others in their countries. They introduce new methods in existing services and make them more effective. They establish health services new to their countries, and they undertake research. More countries participating Fourth, a very high percentage of fellows are taking an active part in training programs and thus passing on to others the benefits they have themselves received. One result of this has been an impressive increase in the number of countries and territories receiving fellows for study urposes. In the earlier years, 1947—49, WHO fellows were placed in about 20 countries; since 1954, the facilities of 80 countries and territories have been used. Part Of this increase has been due to the organization of courses and of training and demon- stration projects with WHO assistance. The use of training facilities in nearby countries, where conditions are more similar to those of the fellow’s own country, has also been deliberately promoted. In the early period about 40 percent of the fellowships were granted for studies in the same region; the proportion is now almost 70 percent. Overall planning Finally, the fellowships have gradually evolved as parts of a broader, better integrated health program for individual nations. In 1956 nearly half of the fellowships awarded (from all sources Of funds) formed part of projects which provided for other types of assistance as well. This evolution of the fellowships program was not due to . chance. It was brought about by more systematic planning and by an improved organization for advising on study plans and for making 64 UNITED STATES AND WORLD HEALTH ORGANIZATION arrangements with the many hundreds Of institutions throughout the world that receive WHO fellows. Adaptation from experience The fellowship program is not perfect, and it is always being modi— fied. For example, some needed training has not been available. This led, for example, to the development of a 1-year course Of anesthesi- ology in Copenhagen. Indeed about one-third of the fellowships are awarded to attend courses organized or assisted b WHO. This does not include fellowships awarded for courses which HO only promote in the organization. An example of this type is the 2-month course on polio laboratory techniques organized in the United States and in Canada. As another example, some former fellows pointed out that courses in public health were not always best designed to meet their needs. This led to the holding of an Expert Committee in 1958 to discuss the “Foreign Student and the Post raduate Public Health Courses.” Seven deans and professors of schoo s of public health (three from the United States and Puerto Rico) and one Director General of Health participated from seven countries and territories, under the chairman- ship of Dean Ernest Stebbins of the Johns Hopkins School of Hygiene and Public Health. The committee pointed out that the detailed questions under discussion Were raised in connection with the training of foreign students but, in many cases, the discussions applied equally well to foreign students and nationals. A number of detailed recommenda— tions were made, including mention of existing plans to benefit from the opinions of the countries and international agencies sending students to the courses. A recommendation was made for the assign- ment of experienced personnel of these agencies to the schools. The committee also took the initiative tO recommend that WHO. undertake, with the schools and national health administration, to study the present development of the schools of public health and to develop minimum requirements or general guidelines for postgraduate courses. These would be designed to be of help to the health adminis— tration, the schools, and the international agencies in raising educa- tional standards throughout the world. Finally, as in the case of our own U.S. programs, it is found that some fellows find it difficult to adjust to their own countries after returning from countries where living standards are higher. This is one of the practical problems inherent in undertaking to work with a large and diversified world as a unit. But with all of the problems, the fellowship program is a remark- able example of or anization Of resources in an unprecedented way to meet urgent hea th problems. Need for posttm'im'ng opportunities It cannot be stressed too often how crucial are the actual oppor- tunities provided by their respective governments and health estab— lishments to fellows after completion of their WHO studies. The WHO effort may be likened in some respects to planting of seeds. Because of limited resources, the seeds are often relatively few and far between. The ground, so to speak, must therefore be well pre- pared and well tended. UNITED STATES AND WORLD HEALTH ORGANIZATION 65 2. PROVIDE TECHNICAL SKILL BY EXCHANGE Bringing people from one country to another to teach complements the WHO fellowship program as a means of spreading technical skill. A form of assistance often requested from WHO is the provision of teaching staff to educational institutions for 1, 2, or more years. From 1952 to 1957, 86 professors Were appointed to 42 schools in some 20 subjects, for a total of 1,482 working months. Of these ap- pointments 50 were in the basic sciences (anatomy, physiology, bio- chemistry, pharmacology, and pathology), 31 in preventive medicine, public health, epidemiology, and statistics, and 23 in pediatrics and child health. Details of the corresponding activities in nursing are given in the part on that subject. The functions of WHO visiting professors are the organization or reorganization of a department in the school, the teaching of students, the establishment of the necessary relationships within the school and with other professional or nonprofessional persons or bodies in the community and, quite often, the inauguration of one or more research projects. Their paramount duty, however, is to train local staff, so that at least one person is capable of taking over the work when WHO assistance ends. WHO usually also provides a certain amount of teaching equipment and medical literature. The establishment of a new department in a medical school is a difficult task. The administrative or legislative formalities for estab- lishing a new Chair are generally simple, but to set into operation an effective new teaching department is a long and arduous process. Some of the results achieved by a single visiting professor in an individual school have greatly exceeded original expectations. For instance, a WHO visiting professor was assigned to establish a depart- ment of pharmacology in the Seth G. S. Medical College in Bombay. As a result a pharmacology department has now been established not only in that college, but in the three other medical schools of Bombay. The funds for these other three departments came from sources out- side WHO, although WHO’s technical advice was freely given when requested. This shows how a project of originally limited objective may have a wider influence by the example it sets and the stimulus it gives. Visiting teams ' Visiting professors may work with their host faculties over a period of years. In a different type of project, a group of professors briefly visit faculties. These visiting teams are as a rule composed of 8 to 14 professors or scientists of international standing, representing basic science and clinical subjects as well as public health and preventive medicine. They transmit the latest developments in their subjects by informal contact with‘their local counterparts and, more widely, by formal lectures or seminar—type discussions and demonstrations. The influence of visiting teams on academic and governmental au th- orities, and on the general public, has often brought about improve- ments that might otherwise have been delayed. Visiting teams are concerned with all problems of medical education. Their visits give an opportunity for conferences on medical education in which the team joins with the local authorities. In the last 10 years, teams have visited 37 medical schools in 13 countries, and 132 professors from 52 different medical schools have taken part in them. 66 UNITED STATES AND WORLD HEALTH ORGANIZATION These visiting teams have not only produced remarkable results with a small outla of money, but have set a sound precedent for extension of the WIIO research program. The nature of research is such that communication is of paramount importance. The patterns adopted for medical education can apparently be adapted easily to research, which is intertwined with graduate teaching. 3. COLLECT, ANALYZE, AND DISTRIBUTE INFORMATION Another general objective of WHO has been to make information on training institutions and methods for the health professions more widely known throughout the world. To attain this objective, studies, surveys, and analyses of two kinds have been done: first, those con— cerned with the personnel needs, resources and facilities of individual countries or groups of countries in order to assist them in planning training programs; second, those dealing with information and educa- tion problems of international interest, for the use of the world at large. In the first category, a number of nationwide surveys and studies on medical education have already been mentioned. Some of them were made by individual experts, others were based on reports made by visiting teams of medical scientists and were therefore the composite views of groups of senior academic teachers. In the southeast Asia region, for instance, surveys of one kind or the other have been made in all but one of the member states. Enough material has been col- lected for an analytical study of medical education in the region. In the second category, a summary worldwide survey of medical education has been made in connection with the publication of the second edition of the “World Directory of Medical Schools.” It contains tabular information on approximately 650 medical schools of all countries. It is preceded by a narrative describing all the im- portant features of undergraduate medical training in 83 countries. This sort of background information is not only an essential tool for WHO’S operating programs, but a new way of assessing the resources of the world for health protection. Part IV DEVELOPMENT OF WHO’S MEDICAL RESEARCH The world is poised to enter a new era of medical research. Answers to the major health problems of the world cannot be found by research confined within national boundaries. A vast international medical . research effort is required to supplement national efforts. Studies not merely on national but on a world basis are required to deal with questions such as these: 1. Why does cancer attack certain parts of the body many times more frequently in some parts of the world than in others? Is there such a thing as inherited susceptibility to cancer? Or are there environmental influences—such as food, or irritants, or climate—that afiect susceptibility? L If the answers to these questions were known, long steps would have been taken toward solving the riddle of cancer. 2. Do such diseases as epilepsy and rheumatism differ in nature and incidence throughout the world? The answer to this question is not known, and information must be available if a worldwide attack on such diseases is to be mounted. 3. What effects do events shortly before, durin , and after birth have upon health—upon, for example, the c ances of a child being born deformed? A worldwide investigation, carefully planned to shed light on the most important questions by comparative studies involving geographic, racial, economic, and health differences among mothers, would go far toward providing answers. 4. How can the virus diseases be brought under the same con- trol as most of the bacterial diseases? The field of virus research, including problems as diverse as the relationship of viruses to cancer and to heredity, the worldwide transmission of certain viruses by migration of birds, and the common cold, is expanding with explosive force. Nothing less than a worldwide effort involving the best scientists of the globe is adequate to make full use of the discoveries that are pouring from the world’s laboratories faster than they can be assimilated into the body of scientific knowledge. The very collection of different types of viruses from differ- ent parts of the world, with different climates and other factors, is a matter of greatest importance. So far as the United States is concerned, full cooperation in all such studies provides an opportunity to join other nations in a common effort to defeat disease, and to increase the efficiency of its own na- tional medical research effort. The World Health Organization is the natural instrument for the planning and coordination that will be required if the nations of the 67 68 UNITED STATES AND WORLD HEALTH ORGANIZATION world are to seize the opportunity before them. For this reason, this part of the report recounts some highlights of WHO’S research experience over the past 10 years. A. CONSTITUTIONAL BASE WHO’S constitution provides not only that a function of the organi- zation 1s——— to promote and conduct research in the field of health (art. 2, sec. (n)), but also that a function of the Health Assembly is to promote and conduct research in the field of health by the personnel of the Organization, by the establishment of its own institutions or by cooperation with oflicial or nonoflicial institutions of any member with the consent of its government (art. 18, sec. (R)). Within this broad charter, the continuing policy problem for the Organization has been not whether health research should be sup- ported, but rather what kind and how much research should be pro- moted and conducted, and the means of promoting research. It should be borne in mind when reading this section that WHO’S trainin and educational programs (pt. 3) have contributed sub- stantia lywto research throughout the world. B. EARLY PROGRAM PRIORITIES In the early days of the organization, the consensus was that much more was already known about health protection against important . diseases than was being applied. For this reason, the development of research was not conSIdered a matter of top priority when the pro- gram objectives were first set. This 1949 resolution of the Second World Health Assembly was an important policy guide: Whereas the development of planned programs requires continuous application of research and investigation on many problems, the solution of which may be found essential for the diagnosis, treatment and prevention of disease, and for the romotion of positive health; hereas research includes field investigations as well as those conducted in laboratories, The Second World Health Assembly— Resolves, That the following guiding principles should be applied in the organ- ization of research under the auspices of the World Health Organization: (1) research and coordination of research are essential functions of the World Health Organization; (2) first priority should be given to research directly relating to the pro— grams of the World Health Organization; (3) research should be supported in existing institutions and should form part of the duties of field teams supported by the World Health Organization; (4) all locally supported research should be so directed as to encourage assumption of responsibility for its continuance by local agencies where indicated; (5) the World Health Organization should not consider at the present time the establishment, under its own auspices, of international research insti- tutions. Priorities in 1948 Early program priorities of the organization set by the First World Assembly in 1948 were as follows: , Priority group I Venereal diseases, tuberculosis, malaria, maternal and child health, nutrition, and environmental sanitation. UNITED STATES AND WORLD HEALTH ORGANIZATION 69 Priority group II Public health administration, including hospitals and clinics, medical care, medical rehabilitation, medical social work, nursing, health education, industrial hygiene, and the hygiene of seafarers. Priority group III Ankylostomiasis, filariasis, leschnaniasis, schistosomiasis, and trypanosom1as1s. Priority group IV Virus diseases, including poliomyelitis, trachoma, influenza, and rabies. Priority group V Mental health. Priority group VI Brucellosis, technical education, and procurement of medical supplies. The major lines of early WHO research were set as a general, albeit not rigid, guide by these program priorities, plus the policy that research relating to them should take precedence over other research. As the organization matured, increasing attention was paid to re— search on the chronic diseases, such as cancer and heart disease. This tendency was, as explained hereafter, markedly acclerated as a result of a farsighted gift in 1958 Of $300,000 to WHO from the United States for planning of WHO’S role in the international stimu- lation and Coordination of research. C. THE RESEARCH CENTER APPROACH Research needs quickly developed as disease control programs expanded. In the preceding part, the need for influenza centers was spelled out. The concept of these centers was adapted to other disease agents: Poliomyelitis (chart 4—A) treponematosis, lepto- spirosis, brucellosis, shigella infections, salmonella, and escherichia infections. Each set Of centers cooperates in the study Of specific problems and compares and classifies organisms isolated in various parts of the world for the purposes of epidemiological study under standard comparable methods. As an example, 15 WHO/FAQ brucellosis centers are currently investigating epidemiological and control problems Of brucellosis. As another example, with the uncovering of extensive leptospirosis infection among domestic animals the epidemiology Of the disease takes on new interest. Six WHO/FAQ Leptospirosis Reference Laboratories have been concerned in promoting greater uniformity of diggnosis, particularly with regard to classification and typing pro- ce ures. The research centers are stressed at this point as a technique for stimulating and coordinating research because, as will be seen later, this device may well have broad applicability to a further expansion Of WHO’S research activities. ‘ WHO Pouc') c NTRES .- AT APR I958 0L NOLLVZINVDHO I-IJIIVEII—I (I'I‘HOAA GNV SELLVLS GELLIMII UNITED STATES AND WORLD HEALTH ORGANIZATION 71 D. INFECTIOUS DISEASES As the WHO generally followed the Operational priorities set by the First Vigrld Health Assembly, an extensive research program gradually emerge . The inevitability with which research followed the development of control programs was epitomized by the malaria program, discussed in the preceding part. In the pages Which follow, selected WHO research activities are described in order to illustrate the variety of research approaches followed, the general areas of concentration of research, the coopera- tive arrangements that typify the program, the major disease areas covered, and the various relationships between disease control pro- grams and research. The section is not, however, a complete catalog of WHO’S research activities. 1. Tuberculosis As was true of malaria, the tuberculosis control programs immedi- ately encountered difficulties calling for research. For example, the BCG vaccine for tuberculosis is generally regarded as valuable under certain conditions, and WHO developed mass vaccination campaigns. Precise evaluation of the effects of these campaigns was, however, difficult because the extent and duration of protection conferred by the vaccine could not be precisely measured. WHO set up a Tuberculosis Research Offi ce in Copenhagen to solve this and and other problems relating to tuberculosis. This office developed methods for evaluating the results of mass BCG vaccination campaigns in terms of allergy production, a useful index for assessing both the vaccines and the techniques used in these projects. As another example of TB research there is some evidence of several types of tuberculosis micro-organisms other than the well-known human, bovine, and avian. Investigations are currently being under- taken in Africa and India into the types of tubercle baccilli isolated from human and animal populations. Field teams collect sputum specimens from randomly selected population groups in various coun- tries for the laboratories participating in this research program, as coordinated by WHO. This work illustrates both the need for a world approach in dealing with many medical research problems, and the experience which WHO has gained in the practical problems of organizing and carrying out such studies. 2. Trachoma, Trachoma, a blinding eye disease now known to be carried by a virus, and.infectious conjunctivitis affect no less than 400 million people (see p. 52, “The Status of World Health”). They present a ave social problem because of the high percentage of blindness. Trachoma may reach very high percentages of infection among children, and in some territories of North Africa the percentage is often ashigh as 70—90 and may even reach 100 percent. In other territories of Africa, evidence during the last years has shown that trachoma is a more important problem than it was hitherto believed to be in certain areas of French territories in west and Equatorial Africa, Ghana, Kenya, and South Africa. A very high incidence has been detected in several areas of the Middle East as well as of Iran, India, Indonesia, and China, in Asia. 72 UNITED STATES AND WORLD HEALTH ORGANIZATION The bacterial types of conjunctivitis which may cause blindness and other complications in themselves, produce yearly epidemics and are associated in varying frequency with trachoma in the different countries. This association prolongs and makes the evolution of trachoma more severe. . The WHO Expert Committee on Traehoma which met in 1955 recommended that the Organization stimulate research with a view to establishing the identity of the trachoma virus and the bacteriology of the associated conjunctivitis. A long—term program of coordinated research in this field has since been established among institutions in the United States, United Kingdom, and Italy, Switzerland, and Tunisia. It is planned to extend this research to include laboratories in Ethiopia, Japan, Vietnam, India, Turkey, Morocco, and Australia. The Lister Institute in London has isolated a virus and has indicated its readiness to circulate the strain to other collaborating institutes. Meanwhile, among those receiving a WHO grant-in—aid are the Institute Pasteur (Tunisia) which has published its work on the isola- tion of a virus which it is willing to circulate for further study. With the recent isolation of the virus of trachoma, the disease is now ripe for an intensive research effort using modern techniques of virology. ‘ 3. Yaws and syphilis Some 50 million people are infected with yaws, but elimination is now practical (p. 50, “The Status of World Health”). Active WHO projects are now in operation in the Cameroons, French West Africa, Ghana, Liberia, Nigeria, Sierra Leone, and Togoland in Africa; India, Indonesia, Laos, Malaya, and Thailand in Asia; and also in some of the Caribbean Islands, Haiti, the Philippine Islands, a number of Pacific islands, and west New Guinea. Control campaigns—mass treatment with penicillin—have already achieved a substantial decrease in the prevalence of clinical yaws. Nearly 90 million persons have been examined, and 22 million have been treated as active cases or contacts. At resurveys of these populations it has been found that clinically active yaws has fallen from an average prevalence of about 10—12 percent, to 1 percent, and in some areas no active cases at all have been discovered. This means that the transmission of the disease has largely come to an end. Thus, while the progress of the disease has been checked in persons infected when the campaign was begun, new infections have been very few. Thereby, the health of the country has greatly benefited both now and in time to come. The future extension of the campaign against yaws, now that most areas of high prevalence have been covered, will carry it into the less affected districts-where some adaptation of technical policy will no doubt be required. The importance of adequate provision of rural health centers in the supervision of yaws, until eradication is complete, is apparent. The battle against endemic syphilis is proceeding in Bechuanaland, Iraq, Syria, and other countries. It has achieved almost complete success in Yugoslavia. The prevalence of venereal syphilis has for some years been relatively low in the more developed countries. In fact, the reduction in antisyphilitic measures in some of these countries has led to a recent increase in the disease. UNITED STATES AND WORLD HEALTH ORGANIZATION 73 The research prerequisite to the control of syphilis and yaws was done some years ago with the development of penicillin. Now the problem is primarily one of applying the research findings effectively. But research is still needed. Investigations into problems in this field with which WHO has been concerned have been partly initiated by the Expert Committee on Venereal Diseases and the Trepone- matoses and the Subcommittee on Serology and Laboratory aspects or have arisen from the needs of the field program of the Organization. The work Was carried out at certain designated centers in cooperation with other laboratories and clinics in many parts of the world and was coordinated by WHO. In some cases grants were also awarded. At the International Treponematosis Center at Baltimore, Md. , the mutual relationships of the treponemes of yaws and endemic and venereal syphilis and their unchanged susceptibility to penicillin have been investigated. Immunological studies have indicated important developments in serological tests for the treponematoses using tre- ponemal antigens. At the WHO serological. Reference Laboratories in Copenhagen (1950) and Chamblee, Ga. (1954), investigations on the standardiza- tion of antigens and on the preparation of standard freeze-dried re- active sera for the reagin tests for syphilis have made possible improved techniques. The observation that certain batches of penicillin did not appear as effective as others led to coordinated study which resulted in recommendations of certain criteria, especially the duration of blood level in human volunteers, which has made possible the use of single and relatively small doses of penicillin in mass campaigns against ‘ yaws and endemic syphilis. Other investigations have been concerned with the introduction and dosage of penicillin in mass campaigns against endemic syphilis and with the treatment that should be adopted with different prevalences of clinically active yaws. Inquiries have also been made in the dosage of penicillin in use throughout the world. E. NONINFECTIOUS DISEASES AND SPECIAL PROBLEMS While WHO’S research efforts have been conCentrated on problems related to infectious diseases, noninfectious diseases and special problems have been the subject of research eflorts. UNICEF and FAQ have been particularly active in this connection. 1. NUTRITIONAL RESEARCH Millions of people throughout the world suffer from nutritional diseases, and elimination of these is a major public health problem of the world. A brief discussion of some of them will indicate how research is related to disease control measures in various ways. Of the deficiency diseases, kwashiorkor, or protein deficiency, is the most serious from the public health point of view. The first complete clinical account of this disease was given in Ghana, but the prevalence in the world is not known. The condition is associated with insufficient total protein intake, or a la k of balance of certain compounds called amino acids, especially arouiid the period 38516—59—6 74 UNITED STATES AND WORLD HEALTH ORGANIZATION ofdweaning. The majority of sufierers are between 9 and 36 months 0 . The prevention of the disease involves fundamental changes in the way of life of the people and requires cooperativevefforts on the part of health, agricultural, economic, fisheries, and education departments. Disorders connected with insufficient or unbalanced food have to be approached from an educational point of view, because it is difficult to persuade people to change traditional food habits, quite apart from any uestion of cost or technique. The most effective channel is possib y education in nutrition through the maternal and child health centers. New protein sources 4 A great deal Of research of both the laboratory and the field type isingomg on. Most of it is devoted to discovering ways of feeding c " dren and providing sufficient protein without using relatively costly foods such as milk, eggs, etc. Research is now underway in India, Africa, and Central America to find suitable vegetable and fish sources of protein. It is helped by WHO and the Pan-American» Health Organization through small grants to participating institutions. In collaboration with the Josiah Macy, Jr., Foundation and FAQ, a meeting was convened of biochemists engaged in the experimental feeding of animals, scientists studying the most efficient methods of feeding stock, as well as of pediatricians and general medical nutri- tionists. A small protein advisory group has also been formed, the members of which conduct tests on different foodstuffs in their own laboratories. The Rockefeller Foundation has generously donated a sum of $250,000 to further research in this field by grants to institutions in Japan, Taiwan, India, south, east, and west Africa, Mexico, Guate— mala, United States, United Kingdom, and France, whose work is coordinated by WHO. A great deal of progress has been made in this extensive research, and there are now some protein-rich vegetable foods on trial. Special work has been done in Uganda, Coonoor (India), and Guatemala, and recently in other centers of investigation, especially in the Institute for Nutrition of Central America and Panama (INCAP). Coping with pellagra Efforts have been made recently to control and eradicate pellagra. Studies were carried out in Yugoslavia, Egypt, and Basutoland. Epi— demiologically the disease is most frequently associated with grossly restricted intake of food with little variety and with a predominance of maize in the diet. The reduction of pellagra is not a gigantic prob- lem and no research is needed on the disease itself. The solution is a social problem essentially dependent on altering the diet pattern rather than providing an specific treatment. This may mean a change in agricultural p0 icy with the addition of certain special techniques. Some demonstration programs indicated that the enrich- ment Of maize with niacin in the small mills was an effective measure which could sometimes be introduced without difficulty. Deficiency diseases Other nutritional diseases include the deficiency group of which beri- beri is one of the most important. It is well known that it’ usually 4 See pt. V, sec. 0 (2) and (3) {or discussion of nutrition activities in conjunction with FAO and UNICEF. UNITED STATES AND WORLD HEALTH ORGANIZATION 75 occursIamong thosejwhozconsume a diet composed mainly of highly milled rice, and it is rare with any other cereal. The research needed here is social—how to alter diet patterns. Endemic goiter Endemic goiter is another deficiency disease Which bears much re- sponsibility for poor social and economic conditions as well as ill health. It has been estimated that there are some 5 million persons suffering from goiter in India alone. It is generally admitted that endemic goiter can be prevented by the administration of appropriate amounts of iodine. Nonetheless, the practical difliculties the less-developed areas have to face are seri- ous. N 0 method had been devised for the iodization of crude salt— generally used in underdeveloped countries—which would be compa- rable in effectiveness to the iodization of refined table salt by the addi- tion Of iodine in a certain form—iodides. Iodides added to crude salt have proved unstable. Research which the Chilean Iodine Educational Bureau of London undertook, at the request of WHO, produced a simple technique for the iodization of crude salt and showed that another sort of iodine compounds—iodates—were more stable than iodides in crude salt under tropical conditions. Further research work carried out in the United Kingdom and the United States ruled out the danger of toxicit of these iodates. Meanwhile their efficiency was established throug field experiments in Latin America and studies in London. As a result of the research, programs of prevention are now going ahead in Latin America, and in India and other countries in Asia. Anemia Anemia constitutes a public health problem of great magnitude, particularly in the underdeveloped and tropical areas of the world. Malnutrition underlies most of these anemias—particularly an anemia caused by or linked with a deficiency of iron in the diet— which affect particularly certain vulnerable groups in the population, i.e. expectant and lactating mothers, infants, and young children. The high rates of maternal mortality in some countries are un uestionably influenced by the prevalence of anemia. Since it is usua’ y a chronic condition, anemia impairs health and working capacity and hence leads to economic loss. WHO is planning a coordinated world research program on iron deficiency anemia. In summary, extensive research is in progress both on causes of nutritional diseases and also into simple and cheap methods of pre- vention. 2. DRUG ADDICTION The multiplicity of paths by which WHO is led into research, and the political, social, and economic questions that sometimes surround ' research are illustrated by WHO activity relating to khat. The plant Oatha edulis (khat) grows wild or is cultivated in many areas of east Africa and in some parts of the Arabian Peninsula. Its leaves are chewed or consumed in the form of an infusion. It has been reported that in some regions of east Africa and in Aden and Yemen many people have become habituated to the consumption of khat, with very serious consequences to their health, earning capacity, and family life, thus creating a grave social problem. 76‘ UNITED STATES AND WORLD HEALTH ORGANIZATION The Commission on Narcotic Drugs of the Economic and Social Council of the United Nations considered this problem in its 13th session (April 28—May 30, 1958) in Geneva. In connection with khat, some countries believe that the fact that excessive consumption of khat leaves is harmful does not by itself justify restrictive action. Diverse substances such as alcohol, tobacco, and other items are certainly harmful if taken immoderately, but no international control is considered necessary in these cases. Opinion holds that it will have to be found that the danger of the leaves is very great, similar to that of narcotic drugs, before international ac- tion proves warranted. Moreover, the economic and social difficul- ties which might be created in some regions by the prohibition of the cultivation of the plant cannot be overlooked. In view of the critical importance of the question of addiction, WHO was asked to sponsor a scientific investigation of the medical aspects of the habitual chewing of khat leaves. Since this entailed the determination of the active -principle(s) of these leaves, the Or- ganization arranged for a collection of khat leaves from different re- gions to be analyzed at the Pharmaceutical Institute of the University of Bonn, where chemical research on the khat alkaloids was already underway. After more than a year’s work this institute succeeded in isolating an alkaloid which is distinct from d—nor—pseudo-ephedrine, up to then generally accepted as the active principle involved. The Institute expects to isolate three more alkaloids and the pharmaco- logical and toxicological properties of all of them will be studied. 3. PHARMACEUTICAL PREPARATIONS AND BIOLOGICAL STANDARDIZATION 5 The establishment of specifications for the quality examination of pharmaceutical preparations has involved research regarding methods to recognize and define the quality of medicinal substances, their purity and activity, freedom from abnormal toxicit , potency, melt- ing temperatures, etc. This research has been partly carried out by members of the Expert Advisory Panel on the International Phar- macopeia and Pharmaceutical Preparations, but other specialists in difi'erent countries have also taken a substantial part. All this work has been done with little financial assistance from WHO. During the last 10 years the Danish Statens Serum Institute and the National Institute for Medical Research in London, have, with some financial support from WHO, engaged in several collaborative biometrical studies in which many laboratories in different countries also took part. These studies involved research into— (a) a suitable method for measuring the antibiotic content in antibiotic preparations and in blood serum; (1)) reference preparations for measuring the serum content of antibodies against poliomyelitis; (c) the stability of biological preparations at high temperatures; (d) an international standard for anti-yellow-fever serum (a study supported by WHO through grants to the West African Eouncfl for Medical Research Laboratories, Virus Research Unit, agos . I See pt. V, sec. E(1) as regards relationships with 13.8. pharmaceutical companies. UNITED STATES AND WORLD HEALTH ORGANIZATION 77 4. CHRONIC DISEASES OF MAJOR SIGNIFICANCE IN THE UNITED STATES With respect to both cancer and heart disease, a major barrier to research on an international basis has been the inability of scientists to compare results obtained in different countries. Diagnostic criteria differ among investigators. Definitions of terms are not uniform. (a) Cancer When, as in the case of cancer, there are some 40 major subdivisions of the disease, a tremendous task of definition and classification must precede many kinds of international studies. In an effort to deal with this problem, the World Health Organization set up a lung tumor center under the guidance of Prof. Leiv Kreyberg, at the Rikshospi— talet in Oslo, Norway, a distinguished scientist with whom I had the pleasure of conferring. WHO, moreover, has plans—whose execution will depend on the availability of funds—t0 establish comparable centers for all major types of cancer. The importance of prompt availability of such funds can hardly be overemphasized. To carry cancer research forward, the World Health Organization invited the International Union Against Cancer to serve as the agent of cancer investigators throughout the world in drafting an interna- tional cancer research program. It then called together in Geneva, three world-known experts to assist in the development of a cancer research program requiring international collaboration. The scien- tists participating in this effort were: 1. Dr. Leiv Kreyberg, professor of pathology, Rikshospitalet, Oslo, Norway. 2. Dr. Harold L. Stewart, chief of the laboratory of pathology, National Cancer Institute, president of the American Association for Cancer Research. 3. Dr. Morton Levin, assistant commissioner for medical services, New York Department of Health. (6) Cardiovascular ailments Dr. C. J. van Slyke, Associate Director of the National Institutes of Health, has written: 6 In recent years, heart disease has been appearing as the cause of death on the death certificate with greater and greater frequency. * a: a: * a: * * Heart disease today knows no international boundaries. However, for all its magnitude and scope, it suffers from a lack of worldwide investigation. Surveys both here and abroad are slowly accumulating information, but this is a slow process. Also, lack of comparability of data often makes meaningful interpretations impossible. We need well-organized studies that can collect clin- ical and pathologic information on heart disease over several years, not just from hospital clinics and private practice but from entire communities. By these means we can learn more about host and environmental factors related to hyper- tension, rheumatic fever, and coronary heart disease. Challenge and hope lie in the simple fact that the morbidity and mortality from heart disease differ with populations and countries. What we learn about the Bantu, the Japanese, %nd the Italians becomes a challenge to us in the United States and in northern urope. Present knowledge of heart disease incidence and mortality in different popu— lations and population segments is rudimentary. We look for some of the answers in vital statistics, but much of the desired data is missing or incom lete and what is available must be carefully analyzed. Wartime experience 0 the 0 The Journal Lancet, Minneapolis, June 1958, vol. 78, N o. 6. 78 UNITED STATES AND WORLD HEALTH ORGANIZATION Scandinavian countries has demonstrated quite clearly that the problems of arteriosclerotic heart disease in a given population can change in as short a time as a year or two. International action has begun on world public health problems involving heart disease. Members of groups such as the International Society of Cardiol- ogy, the International Congress of Internal Medicine, and the World Health Organization have been attempting to meet the universal heart disease problem since World War II. > * * * * * * * WHO might suitably assist in planning and coordinating the development of certain international research efforts which it would be uniquely qualified to foster. Group support for a program such as this would return ultimately to each member nation a positive dividend in the form of improved national health. This is true just as surely as the present interchange of scientists, limited though it is, mutually increases national research skills. Thus, we observe that the same problem of establishing the neces- sary degree of a cement on terms, classification of disease states and the degree of a vancement of disease as a prerequisite to a research program, has existed in the field of heart disease. In collaboration with the National Heart Institute of the US. Public Health Service, WHO in the latter part of 1957 convened a study group on classifica— tion of atherosclerotic lesions. The study group first defined athero- sclerosis and other pathological terms commonly used to describe lesions observed post mortem. It then discussed the classification and grading of atherosclerotic lesions and made a series of recommen- dations on uniform objective methods for making and recording obser- vations. These technical discussions were put in book form for the information of scientists throughout the world. While work on the problem of classification and standardization was going forward, possible lines of research in the cardiovascular field were explored by highly competent scientific groups advisory to WHO. As early as 1954, at the meeting of the Joint FAQ/WHO Expert Committee, a recommendation was made that consideration should be given to relationships between diet and health, especially in the more highly developed countries and in certain segments of the population in many other countries. The Committee suggested for particular study the problem of degenerative heart diseases, including coronary heart disease, angina pectoris, and myocardial degeneration, since there is evidence that abitual diet plays an important part in the development of these conditions. In 1955, a study group considered the geographical pathology of atherosclerosis. It suggested that the apparently marked differences betWeen different countries in mortality statistics of cardiovascular disease—and particularly of atherosclerotic and degenerative heart disease—should be carefully examined in com- parative studies, which should be extended to autopsy findings where the difierences are very marked. The difficulty of correlating clinical diagnosis and autopsy findings was pointed out. The importance of the worldwide coordination of studies by the development of reference laboratories or centers was also stressed. The pattern We see then the pattern of development of WHO research activities relating to heart disease, cancer, and other important chronic diseases. First, the necessary steps to clarify definitions and classification have been taken. SecondLexpert groups have proposed programs of pro- ductive, feasible research. The latter step has occurred well’before UNITED STATES AND WORLD HEALTH ORGANIZATION 79 the member nations have seen fit‘to provide the necessary financial and other backing to carry out the research. - Given the background of initiative for international research arising strongly from qualified scientists, and a background of meager support for WHO research programs in the chronic diseases by member nations, the future of WHO medical research becomes a pertinent subject for examination. F. THE FUTURE OF INTERNATIONAL MEDICAL RESEARCH AND WHO From the committee print entitled “International Medical Re- search,” it is clear that medical research has always been an inter- national undertaking, and that increasing international cooperation is required if medical research is to be most fruitful in the future. This part has shown that WHO has administered an extensive medical research program, albeit principally in connection with the control of infectious diseases. It has pioneered in the practical prob- lems of planning worldwide research efforts. It has built a fund of good will and is accepted throughout the modern scientific world as a neutral sponsor of research. It has built research on an interna- tional basis soundly, and research has gradually evolved from its operating responsibilities. 1958 amendment to Mutual Security Act Such considerations led me to study legislation relating to the role of the UnitedIStates 1n internationa. medical research, particularly through particrpation of this country in research planned and coordi— nated on aniinternational bas1s by WHO. . At this pomt, I should like to clte an amendment wlnch I had drafted and which had been approved by the Congress in June 1958. This amendment added to the 1948 act whlch had authorized U.S. par- ticipation 1n the World Health Organlzation the followmg language: SEC. 6. The Congress of the United States, recognizing that the diseases Of mankind, because of their widespread prevalence, debilitating efl’ects, and heavy toll in human life, constitute a major deterrent to the efforts Of many peoples to develop their economic resources and productive capacities and to improve their living conditions, declares it to be the policy of the United States to continue and strengthen mutual efforts among the nations for research against diseases such as heart disease and cancer. In furtherance of this policy, the Congress invites the World Health Organization to initiate studies looking toward the strengthening of research and related programs against these and other diseases common to mankind or unique to individual regions of the globe. U .S. initiative at Minneapolis assembly Such considerations also led the United States to make certain sug- gestions in 1958 in the 10th Anniversary Commemorative Session of the World Health Assembly in Minneapolis, Minn., which I had the pleasure of attending. We suggested that the WHO might make an intensive examination of its role in medical and health research, as well as world needs and opportunities for expanded research. It would do so with a view to the presentation to the 12th World Health Assembly, of a carefully conceived and well—designed plan to provide increased WHO leadership in this field. Account was taken, in suggesting the study, of the need for more intensive research in relation to problems encountered in campaigns against diseases for which there are effective control measures, such 0 80 UNITED STATES AND WORLD HEALTH ORGANIZATION as malaria, and particularly of the urgent need for expanded re- search in relation to other diseases and public health problems, Especially in the field of chronic illnesses such as cancer and heart 1sease. The suggestion was made in the hope that through the proposed study WHO would find the way to make its greatest contribution to the further development of the total world research potential in medicine and health. Types of WHO research activity It was further suggested that WHO could quite well expand its role in research, with great effect, in the following areas of activity, among others: , ‘ 1. Coordination of research on an international scale through integrated laboratory networks; 2. The identification and definition of gap areas in medical and public health research; 3. Standardization of scientific terminology and methods; 4. Facilitation of communication between scientists and re- search institutions; 5. Determination of unmet requirements for facilities and equipment; 6. Training of research personnel; 7. Promotion and support of scientific congresses, seminars, and other meetings of medical scientists; 8. Stimulation and advice to national and international ofiicial and voluntary agencies in the research area. The United States wisely recognized that an intensive study by WHO might lead to the development of a plan for an expanded WHO role in the furtherance of research that would commend itself to member states. Our country made therefore, as previously noted, a special grant of $300,000 to WHO to enable it to conduct such a study. At the same time, the working paper relating to medical research, as submitted by the US. delegation noted that— It is the present intent of the U.S. Government to provide substantial support to any sound program that may emerge from the proposed study, subject to participation by a number of other member states. ' In studying the progress of research planning by WHO in Geneva, I was particularly impressed, as noted below in part 5~A, with the fact that some of the best scientists and statesmen of science in the world have been willing to help WHO plan its expanded research program. With such talent at its command, the plans that are developed should prove as sound as they can be made by the mind of man. The vast challenge: Old and new dilemmas The challenge is great. Old disease dilemmas and new ones confront mankind. In the former category, it is essential that American know—h0w, achieved through the relative subduing of communicable and infec— tions diseases in our own land, should be made increasingly available to the world. Experiences, for example, of our Communicable Disease Center in Atlanta can hardly be overestimated in their value to a world still largely beset by communicable scourges. UNITED STATES AND WORLD HEALTH ORGANIZATION 81 In the latter category is the broad variety of research problems raised by such a universally significant topic as that of radioactive fallout. ‘ The very mention of the problem of contamination of the atmos- phere raises the entire issue of air pollution, a subject of increasing interest to scientists everywhere. , It is manifest that a great expansion of research into problems of this nature is imperative. The enlarging of WHO research interests will require recruitment of specialists to the Secretariat of the high caliber which the world has come to expect in WHO. As WHO itself so well realizes, the meeting of these research responsibilities will depend upon follow- through by the permanent Secretariat in addition to the work of additional consultants brought in“ for temporary assistance from time to time. Relationship with propésed new institute at NIH Meanwhile, we may anticipate the availability of the proposed new National Institute for International Medical Research, as proposed under Senate Joint Resolution 41, 86th Congress, by US. Senator Lister Hill, and as cosponsored by myself and others. This Institute would become the administrative structure for oversea activity by the present seven categorical institutes, headquartered in Bethesda, Md. WHO can play an invaluable role with the proposed new Institute in identifying problems, in advising on competent sources well qualified to work on collaborative projects, and in catalyzing such collaboration. Experts of our National Institutes of Health have indicated their awareness of the splendid services which WHO is in a position to help make available to the International Institute. Very often a multilateral organization with complete worldwide acceptability can perform services which an agency of any one government, our own, or any other power however highly regarded, could not undertake. Possible epidemiology missions in selected countries are a case in point. WHO surVey missions have proven virtually universally acceptable. A variety of factors might prevent teams of personnel of any one nationality from surveying problems in particular countries. Yet under WHO’S auspices, the same type of research data can be ob- tained with a‘comparative minimum intrusion of factors which might otherwise prevent effective and harmonious survey work. Part V THE INTANGIBLE ASSETS OF WHO The World Health Organization has: been able to stimulate and coordinate disease control and research programs of a very substantial varied, and farflung character on a relatively small budget. This is made possible by the contributed services of individuals, laboratories and organizations, and because of extensive cooperative work‘involv- ing not only contributions but simply working together. The tremendous: store of; well-deserved, good, will thachas: been enerated by the WHO is in fact its most priceless asset. This, com- ined with respect for the work of the organization, makes it possible to draw upon services and facilities which are literally priceless, and which could be drawn together through no other means. Specific examples of unique talents placed at the disposal of WHO will be cited below. While the array of cooperative arrangements devised by WHO is extremely complex, they can be placed in three broad categories for descriptive purposes—cooperation with individuals, cooperation with laboratories, and cooperation with national and international organi- zations. These groupings are somewhat arbitrary. Ultimately coop- erative efforts in international health and medical research depend heavil upon individuals. Nevertheless, the division of the collabora- tive e orts into three kinds is a useful way of examining the farflung network. A. COOPERATION FROM INDIVIDUALS Individuals cooperate with WHO both formally and informally. The willingness of the best public health experts and scientists in the world to contribute their time to international health and medical research activities is indispensable to the planning and operation of WHO programs. From the recent history of WHO, the planning of an extended medical research program offers an instructive example of informal collaboration by individuals. . This task fell into two parts. The first was to outline the general principles which should guide WHO in expanding its research activities. Questions of substantial importance could be answered correctly only through consultation with persons experienced in research and in large scale research administration. To deal with these questions, the Director-General of WHO called together two groups. ' 1. WHO research planning conferences The Director General first invited five advisers to discuss with him in Geneva on August 18—21, 1958, the basic principles that should underlie a study and plan for an expanded research role for WHO. Those in attendance were: Prof. Robert Loeb, Bard professor of medicine, Columbia University, New York. Prof. Charles Oberling, professeur titulaire de la Chaire de Medecine, experi- mentale au College de France, Paris. 83 84 UNITED STATES AND WORLD HEALTH ORGANIZATION Dr. C. J. Pandit, Secretary, Indian Medical Research Council, New Delhi. Sir George Pickering, Regius professor of medicine, University of Oxford, Oxford (member of the British Medical Research Council). Prof. Bror Rexed, Department of Anatomy, University of Uppsala, Uppsala (Secretary of the Swedish Medical Research Council). The participation of a member of the USSR. Academy of Sciences was expected, but unfortunately, arrangements for attendance could not be made. The Director General then convened a somewhat larger group in Geneva on October 20—24., 1958, to discuss in greater detail the general observatlons and suggestions of the first group. Those in attendance were: Dr. Z. M. Bacq, director, Laboratoire de Pathologic et de Therapeutique Gener- ales, University of Liege, Liege (Belgium). Dr. I. Berenblum, professor of cancer research, the Weizmann Institute of Science, Rehoboth (Israel). Prof. N. N. Blokhin, director of the Institute of Experimental Pathology and Thera y of Cancer, Academy of Medical Sciences, Moscow (U.S.S.R.). Dr. i1)harvat, professor of medicine, Charles University, Prague (Czechoslo- va 1a . Dr. R. Doll, lecturer in medical statistics and epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom). Dr. S. Gard, professor of virology, Karolinska Institute, Stockholm (Sweden). Dr. H. Hamperl, professor of pathology, University of Bonn, Bonn (Germany). \ Dr.' C. Heymans, professor of pharmacology, University of Ghent, Ghent (Bel- urn . SiIngarbld Himsworth (Chairman), Secretary, British Medical Research Council, London (United Kingdom). Dr. C. M. MacLeod, professor of research medicine, University of Pennsylvania, Philadelphia (United States). Dr. J. A. Shannon, Director, National Institutes of Health, Bethesda, Md. (United States). - Dr. E. L. Stebbins, dean, School of Hygiene-and Public Health, the Johns Hopkins University, Baltimore, Md. (United States). Dr. Alan 0. Stevenson, director, Population Genetics Research Unit, Medical Research Council, Oxford, (United Kingdom). Dr. A. Vannotti, professor of medicine, University of Lausanne, Lausanne, (Switzerland). Dr. Paul Wood, director, Institute of Cardiology, 35 Wimpole Street, London, W.I. (United Kingdom). The names of those attending the two planning meetings are listed to indicate the noteworthy qualification of those who are willing to give freely of their time to help establish a broader international medical research program. ‘ The three Americans who participated in this conference are each outstandin leaders. Dr. C. M. McLeod is a distinguished researcher; Dr. James hannon is the director of what is universally acknowledged as the world’s foremost research facility, and Dean E. L. Stebbins {wags one of the greatest schools of public health in this or any other an . In London, subsequently, I had the pleasure of making the acquaint- ance of the able conference chairman, Sir Harold Himsworth, a scientist of similar great stature. The second general step in research planning was to examine the significant areas of medical research to determine research needs, opportunities and resources. As an illustration of the quality of the people engaging in this planning, there follows a list of participants \< I UNITED STATES AND WORLD HEALTH ORGANJiZATION 85 in a conference on research on virus diseases held ‘in Geneva on November 17—22, 1958: ' rSClENTIFIC GROUP ON VIRUS DISEASES ‘ November 17—22, 1958 Sir Macfarlane Burnet, Chairman; director, the Walter and Eliza Hall Institute of Medical Research. . Dr. C. H. Andrewes, World Influenza Center, National Instikute for Medical Research. ' ' . Dr. R. Dulbecco, California Institute of Technology, Pasadena Calif. Prof. Sven Gard, Department of Virus Research, Karolinska Infititutet. Dr. J. H. S. Gear, director of research, the Poliomyelitis Rese South African Institute for Medical Research. Dr. R. J. Huebner, Chief, Laboratory of Infectious Diseases, ational Institute (gr Allergy and Infectious Diseases, Department of Health, Education, and elfare. Prof. A. A. Smorodintsev, Department of Virology, Institute ‘of Experimental Medicine, Academy of Medical Sciences, Leningrad. DrMIEi' M. Taylor, Section of Preventive Medicine, Yale University School of e icine. As an indication of the importance attached to tirese planning sessions by scientific leaders, Sir Macfarlane Burnelf, one of the world’s most eminent virologists, flew from Austra ‘a—a 40-hour airplane trip—and back to serve as chairman of a group Which met for 1 week. 2. Expert advisory panels In addition to ad hoc informal conferences, WHO hais an extensive apparatus of formal advisory groups. WHO is in touch with more of the world’s leaders in matters of public health, medical education and research, and rela ed fields than is true of any other organization. This worldwide netw rk of personal relationships enables the WHO to establish panels of h' hly qualified experts Who are available to help the organization. Expert advisory panels supply WHO with techniljal advice by correspondence and individual contact. They are also t e source from which members of expert committees, discussed belox‘if, are drawn. WHO, in turn, keeps panel members informed of de ‘elopments in their fields. - In June 1958 there were 36 panels 7 covering the following subjects: . Addiction producing drugs. . Antibiotics. . Biological standardization. . Brucellosis. ‘ rch Foundation, . Cancer. . Cholera. . Chronic degenerative diseases. . Dental health. . Environmental sanitation. 10. Health education of the public. 11. Health laboratory methods. 12. Health statistics. 13. Insecticides. 14. International pharmacopoeia and pharmaceutical prepara- tlons. ' On these panels larva 1.682 experts residing in 74 countries. {DOONIOBUll-P-OJNH 86 UNITED STATES AND WORLD HEALTH ORGANIZATION 15. International quarantine. 16. Leprosy. 17. Malaria. 18. Maternal and child health. 19. Mental health. 20. Nursing. 21. Nutrition. 22. Occupational health. 23. Organization of medical care. 24. Parasitic diseases. 25. Plague. 26. Professional and technical education of medical and auxiliary personnel. 27. Public health administration. 28. Rabies. 29. Radiation. 30. Rehabilitation. 31. Trachoma. 32. Tuberculosis. p 33. Venereal diseases and treponematoses. 34. Virus diseases. 35. Yellow fever. 36. Zoonoses. The panel structure is flexible with respect to coverage of fields and with respect to individual memberships. For example, extension of panels designed to provide advice on such matters as cardiovascular diseases is under consideration. With regard to membership of individuals, the participation of the USSR. since its resumption of active participation in the affairs of the organization is noteworthy. In 1958 scientists from the USSR. were invited and did participate in 12 out of 25 expert committees convened by the Organization. Russian experts have already been appointed to 32 of the total 36 panels currently in existence. WHO’S expert committees, drawn from the panels noted above, are asked to (a) review the latest knowledge and expert information and make it available to the Organization; (6) to formulate technical rec- ommendations; (c) to make recommendations designed to initiate, stimulate and coordinate research necessary for the fulfillment of their terms of reference. Nearly 200 expert committee meetings have been so far convened.- They were attended by approximately 500 panel members from about 40 countries. The reports of such meetin are published in the WHO Technical Report Series after the approva of their publication by the Executive Board. This series is a set of corporate technical opinions compounded from worldwide resources. It is noteworth that “the text of a report of an expert committee may not be modi ed Without the consent of the committee by which it was drawn up.” These reports therefore represent the actual opinion of the experts. The expert panels and committees serve both technical and non— technical functions: 1. They provide a simple and efficient means of organizing _ and usin the best brains of the world for the solution of inter- national ealth problems. UNITED STATES AND wORLD HEALTH ORGANIZATION 87 2. They'are a means by which unique local or regional problems can be dealt with in a larger setting. 3. They are a device for supplementing the work of the WHO secretariat without adding to secretariat employment. 4. They are a device through which cultures and traditions are necessarily blended in adapting disease control measures, educa- tional and research programs to needs and desires of countries throughout the world. 3. American delegates to health assemblies As previously indicated, it has been my personal pleasure to serve as a delegate to the World Health Assembly. Members of Congress may wish to note the caliber of the other Americans in public and private life Who have represented our country at the conferences and World Health Assemblies, held to date. (See table 5—A, below.) TABLE 5—A.-— U.S. delegations to International Health Conference and World Health Assemblies—1 st through 10th 3 Ward P. Allen, American Embassy, Copenhagen, Denmark (IHC). Dr. Gaylord Anderson, director, School of Public Health, University of Minne- sota, Minneapolis, Minn. (4th). Homer D.'Angell, 2931 SE. Hawthorne Boulevard, Portland, Oreg. (4th and 6th). Hon. William H. Avery, House of Representatives, House Office Building, Wash— ington, D.C. (8th). Capt. R. W. Babione, Armed Forces Epidemiological Board, Office of the Surgeon General, Department of the Army, Washington, D.C. (2d). Dr. Theodore C. Bedwell Jr., Deputy Surgeon, Strategic Air Command, OfTutt Air Force Base, Nebr. (9th). Dr. D)aniel Bergsma, State commissioner of health, Trenton, N .J . (N CC, WHO; 9th . Donald C. Blaisdell, professor of political science, City College of New York (5th). Dr. Frank G. Boudreau, director, Milbank Memorial Fund, 40 Wall Street, New York, N.Y. (IHC, NCC, WHO). Dr. Frederick J. Brady, program officer, Bureau of State Services, Public Health Service, Department of Health, Education, and Welfare, Washington, D.C. (3d, 4th, 5th, 6th, 7th, and 8th). Dr. Otto Brandhorst, secretary, American College of Dentists, Lindell Boulevard, St. Louis, Mo. Gen. Shelden S. Brownton, Executive Assistant to Secretary of Defense for Health and Medical Services, Department of Defense, room 3E7751, The Pentagon, Washington, D.C. (7th). Leroy E. Burney, M.D., Surgeon General, Public Health Service, Department of Health, Education, and Welfare, Washington, D.C. (8th and 10th). Lester W. Burket, M.D., dean, Dental School, University of Pennsylvania, Philadelphia, Pa. (10th). Howard B. Calderwood, Ph. D., Office of Economic and Social Affairs, Depart- ment of State, Washington, D.C. (IHC; 1st through 10th). Col. Robert L. Callison chief, preventive medicine, medical section, Headquarters, 2d US. Army, Fort George Meade, Md. (10th). Dr. Eugene P. Campbell, Chief, Public Health Division, International Coopera- tion Administration, 806 Connecticut Avenue NW., Washington, D.C. (10th). Dr. Melvin A. Casberg, vice president for medical affairs, University of Texas, Austin, Tex. (5th). . DrCRoy (Clears, executive director, Colorado State Department of Health, Denver, 010. 4th . Dr. Lowell T. Coggeshall, dean, Division of Biological Sciences, University of Chicago, 950 East 59th Street, Chicago, Ill. (9th). Wendell B. Coote, American Embassy, Helsinki, Finland (9th). Dr. Francis P. Corrigan, 531 East 20th Street, New York, N.Y. (1st). Dr. Edwin L. Crosby, executive director, American Hospital Association, Balti— more, Md. (10th). Nelson H. Cruikshank, social security director, AFL—CIO, room 307, 815 16th Street NW., Washington, D.C. (lst). * 0 Titles and affiliations represent the most current biographical data available as of the present time. 88 UNITED STATES AND WORLD HEALTH ORGANIZATION Mrs. Fannie Hurst Danielso'n (Jacques S.) 1 West 67th Street, New York, N.Y. (5th). Drétglbert W. Dent, President, Dillard University, New Orleans, La. (lst and Dr. Harold S. Diehl, medical director, senior vice president for research and medical afl’airs, American Cancer Society, 521 West 57th Street, New York, N.Y. (7th and 8th). Dr. James A. Doull, medical director, Leonard Wood Memorial, 1832 M Street NW., Washington, D.C. (IHC; lst). Mrs. India Edwards, 4000 Massachusetts Avenue NW., Washington, DC. (4th). Dr. Rolf Eliassen, professor sanitary engineering, Massachusetts Institute of Technology, Cambridge, Mass. (5th). Dr. Martha M. Eliot, professor maternal and child health, Harvard School of Public Health, 55 Shattuck Street, Boston, Mass. (IHC; 1st; NCC; and WHO). Hon. Allen J. Ellender, US. Senate, Senate Office Building, Washington, D.C. (2d). Dr. Harold M. Erickson, State health oflicer, State Board of Health, 1400 SW. Fifth Avenue, State Office Building, Portland, Oreg. (7th). MisNiliatgaggne E. Fayville, dean, College of Nursing, Wayne University, Detroit, rc . . Dr. Robert E. Felix, director, National Institute of Mental Health, National Institutes of Health, Bethesda, Md. (2d). Hon. Ivor D. Fenton, House of Representatives, New House Office Building, Washington, D.C. (lst). Dr. Robert P. Fischelis, secretary—general manager, American Pharmaceutical Association, 2215 Constitution Avenue NW., Washington, D.C. (IHC). Mrs. Marcia M. Fleming, Ofl‘ice of the Assistant Legal Adviser for United Nations Affairs, Department of State, Washington, D.C. (IHC . Hon. John E. Fogarty, House of Representatives, 1133 New House Office Build- ing, Washington, D.C. (when Congress is not in session, 200 Customhouse Building, Providence, R.I.) (10th). Dr. George M. Foster Department of Anthropology, University of California, Berkeley, Calif. (5th). Dr. David French, dean, Flynt College, University of Michigan, Flynt, Mich. (8th). Dr. Vlado A. Getting, School of Public Health, University of Michigan, Ann Arbor Mich. (3d). Wesley . Gilbertson, assistant chief, Division of Sanitary Engineering Services, Public Health Service, Department of Health, Education, and Welfare, Wash— ington, D.C. (4th). Dr. Wilton L. Halverson, School of Public Health, University of California, Los - Angeles, Calif. (1st). Dr. John H. Hanlon, director, Public Health Services, Department of Public Health, room 531, City Hall Annex, Philadelphia, Pa. (7th). Hon. Wayne L. Hays, House of Representatives, room 1007, New House Office Building, Washington, D.C. (6th). Joseph S. Henderson, Director, Visa Oflice, Department of State. (5th). Dr. Harold Hillenbrand secretary, American Dental Association, 222 East Supe- rior Street, Chicago, Ill. (7th). Mark D. Hollis, chief engineer, Division of Sanitary Engineering Services, Public gegltlégfrvice, Department of Health, Education, and Welfare, Washington, Dr. H. van Zile Hyde, assistant to the Surgeon General for international health, Public Health Service, Department of Health, Education, and Welfare, Wash- ington, D.C. (IHC; 1st through 7th, 9th, and 10th; also present at 8th as representative of the Executive Board.) George M. Ingram, director of administration, American Embassy, Baghdad, Iraq. (2d and 4th). Hon. Walter H. Judd, House of Representatives, room 1225, New House Office Building, Washington, D.C. (3d). Leo W. Garvey, Office of International Conferences, Department of State, Wash- ington, D.C. (10th). Dr. Chester S. Keefer, Evans Memorial Hospital, 65 'East Newton St., Boston, Mass. (7th). Dr. Morton M. Kramer, Chief, Biometrics Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Md. (lst). Miss Carol C. Laise, American Embassy, New Delhi, India (6th and 7th). UNITED STATES AND WORLD HEALTH ORGANIZATION 89 Dr. Leonard W. Larson, member board of trustees, American Medical Associa- tion, 221 Fifth St., Bismarck, N’. Dak. (5th and 6th). David B. Lee, director, Bureau of Sanitary Engineering, State Department of Health, Jacksonville, Fla. (2d). Dr. Richard K. C. Lee, president, Board of Health, Honolulu, T.H. (10th). HcgnYthrbfirit H. Lehman (former U.S. Senator), 41 East 57th St., New York, . . 4t . Mrs. Lucile Petty Leone, Chief Nurse Oificer, Public Health Service, Department of Health, Education, and Welfare, Washington, D.C. (1st). Mrs. Adele R. Levy, New York Fund for Children, Inc., 100 Park Ave., New York, N.Y. (lst). Dr. George Lull, formerly secretary and general manager, American Medical Association, 535 North Dearborn St., Chicago, Ill. (IHC). John Maktos, Assistant Legal Adviser for Near Eastern, South Asian, and African Afl’airs, Department of State, Washington, D.C. (IHC). Dr. Charles W. Mayo, chairman, Mayo Association, Mayo Clinic, Rochester, Minn. (8th and 9th). Dr. Edward G. McGavran, dean, School of Public Health, University of North Carolina, Chapel Hill, N.C. (5th). Dr. Edward J. McCormick, American Medical Association, room 501, Owens- Illinois Building, Toledo, Ohio (3d). Dr. Aims C. McGuiness, Special Assistant for Health and Medical Affairs, Depart- ment of Health, Education, and Welfare, Washington, D.C. (10th). Miss Pearl McIver, executive secretary, American Journal of Nursing 00., 2 Park Ave., New York, N.Y. (9th). D1;i Echard S. Meiling, Ohio State University Hospital, Columbus, Ohio (3d and t . Dr. James R. Miller, 7 Banbury Lane, West Hartford, Conn. (1st and 2d). Dr. Lloyd G. Miller, director of revision, Pharmacopoeia of the United States of America, 46 Park Ave., New York, N.Y. (5th). Hon. Thomas E. Morgan, chairman, Committee on Foreign Affairs, House of Representatives, room 502, Old House Office Building, Washington, D.C. (4th and 8th). Dr. Henry B. Mulholland, assistant dean, School of Medicine, University of Vir inia, Charlottesville, Va. (4th). Otis . Mulliken, Deputy Chief, Office of International Economic and Social Affairs, Department of State, Washington, D.C. (IHC). Dr(. Eganklin D. Murphy, chancellor, University of Kansas, Lawrence, Kans. 6t . Dr(.4('i1a5rl N. Neupert, State health oflEicer, State Board of Health, Madison, Wis. t . ' Hon. Richard M. Nixon, the Vice President, U.S. Senate, Washington, D.C. Dr. J. W. R. Norton, State health officer, Raleigh, N .0. (8th). Mrs. Agnes Ohlson, State Board of Nurse Examiners, State Ofl'ice Building Annex, Hartford, Conn. (8th). Dr. Arthur S. Osborne, international health representative, Division of Interna- tional Health, Public Health Service, Department of Health, Education, and Welfare, Washington, D.C. (8th). Dr. Thomas Parran, president, Avalon Foundation, 713 Park Avenue, New York, NY. (IHC; 1st). Dr. James E. Perkins, managing director, National Tuberculosis Association, 1790 Broadway, New York, N.Y. (lst). Dr. Joseph L. Pfeifer, 58 Bushwick Avenue, Brooklyn, N.Y. (2d). Mrs. Viola R. Pinanski, member, National Advisory Neurological Diseases and Blindness Council, National Institute of Health, Brookline, Mass. (10th). ,Blucher A. Poole, chief, Bureau of Environmental Sanitation, State Board of Health, Indianapolis, Ind. (10th). David H. Popper, deputy U.S. representative for international organizations, American consulate general, Geneva, Switzerland (10th). Dr. James R. Reuling, American Medical Association, Lake Butler Estates, Windermere, Fla. (9th and 10th). Dr. Edward S. R0 ers, professor of public health and medical administration, School of Public ealth, University of California, Berkeley, Calif. (2d). Alvin A. Roseman, director, U.S. Operations Mission, Pnom Penh, Cambodia, (IHC; 1st and 3d). Dr. Paul F. Russell, Westover, North Edgecomb, Maine (1st). 3851 MEI—~41 90 UNITED STATES AND WORLD HEALTH ORGANIZATION Durward V. Sandifer, International Cooperation Administration, Washington, D.C. (IHC; 1st). Dr. Leonard A. Scheele, president, Warner-Chilcott Laboratories, 201 Tabor Road, Morris Plains, NJ. (2d through 7th and 9th). Dr. Thomas F. Sellers, director, Georgia Department of Public Health, State . Office Building, Atlanta, Ga. (5th). Dr. Michael B. Shimkin, National Cancer Institute, National Institutes of Health, Bethesda, Md. (IHC). ' Miss Ruth Sleeper, R.N., director, School of Nursing and Nursing Services, Massachusetts General Hospital, Boston, Mass. (6th). Dr. Calvin B. Spencer, Division of Foreign Quarantine, Public Health Service, Department of Health, Education, and Welfare, Washington, D.C. (9th). Frank M. Stead, chief, Division of Environmental Sanitation, California State Department of Public Health, San Francisco, Calif. (7th). Dr. Ernest L. Stebbins, director, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Md. (10th). Miss Ann Steffen, R.N., dean, School of Nursing, University of California, Los Angeles campus, Los Angeles, Calif. (4th). _ Dr. Robert T. Stormont, secretary, Council on Drugs, American Medical Asso- ciation, 535 North Dearborn Street, Chicago, Ill. (6th). Dr. Knud Stowman, 186 Beach Street, City Island, N .Y. (2d through 6th). Miss Mary E. Switzer, Director, Office of Vocational Rehabilitation, Department of Health, Education, and Welfare, Washington, D.C. (IHC; 2d). Miss Ruth G. Taylor, R.N., chief, Nursing Section, Division of Health Services, Children’s Bureau, Department of Health, Education, and Welfare, Washing- ton, D.C. (5th). John D. Tomlinson, U.S. Consul, Port Elizabeth, Union of South Africa (1st). Capt. Robert I. Ware, executive officer, Naval Hospital, San Diego, Calif. (8th). Robert Olaf Warin , OfliceZOf International Administration, Department of State, Washington, D. . (10th). . Kenneth S. Watson, consultant, water management and waste control, General Electric 00., Schenectady, N.Y. (9th). Dr. Thomas F. Whayne, 316 Windine Way, Merion Station, Pa. (1st and 6th). Mrs. Sara Whitehurst (John L.) 4101 Greenway, Baltimore, Md. (3st). Mrs. Elmire B. Wickenden, R. ., Five the Byway, Bronxville, N.Y. (IHC). Francis 0. Wilcox, Assistant Secretary for International Organization Affairs, Department Of State, Washington, D.C. (9th). Dr. Charles L. Williams, Jr., deputy chief, Public Health Division, International EJOOperation Administration, 806 Connecticut Avenue, Washington, DC. 8th). . * Dr. Louis L. Williams, Jr., consultant, PAHO, Washington, D.C. (IHC). . Dr. Abel Wolman, professor of sanitary engineering, Johns Hopkins School of Public Health and Hygiene, Johns Hopkins University, 203 Whitehead Hall, Baltimore, Md. (IHC; 1st). Hon. Charles A. Wolverton (former Member), House of Representatives, Wash- ington, D.C. (10th). Mrs. Nell Hodgson Woodruff, 3640 Tuxedo Road, Atlanta, Ga. (7th). Mrs. Louise Wright, Midwest director, Institute for International Education, 116 South Michigan Avenue, Chicago, Ill. (2d). Laurence Wyatt, Office of International Economic and Social Affairs, Department of State, Washington, D.C. (7th and 10th). Dr. Franklin D. Yoder, State health officer, Cheyenne, Wyo. (10th). US. delegation to the Ilth World Health Assembly (Minneapolis, Minn., May .98, 1.958 Delegates: Leroy E. Burney, M.D. (chairman); Surgeon General, US. Public Health Service, Department of Health, Education, and Welfare. John W. Hancs, Jr., Administrator for Security and Consular Affairs, De- partment of State. ' Chla/Irles Mayo, M.D., chairman, Mayo Association, Mayo Clinic, Rochester, inn. UNITED STATES AND WORLD HEALTH ORGANIZATION 91 Alternate dele ates: Howard . Calderwood, Ph. D., Office of Economic and Social Affairs, Department of State. Lowegh'l‘. Coggeshall, M.D., dean, Division of Biological Sciences, University 0 icago. H. van Zile Hyde, M.D., Chief, Division of International Health, Bureau of State Services, U.S. Public Health Service, Department of Health, Education, and Welfare. George F. Lull, M.D., formerly assistant to the president, American Medical Association Chicago, Ill. Aims C. Mcéuinness, M.D., Special Assistant to the Secretary of Health, Education, and Welfare for Health and Medical Afl‘airs. Arthur S. Osborne, M.D., international health representative, Division of International Health, Bureau of State Services, U.S. Public Health Service, Department of Health, Education, and Welfare. Congressional advisers: The Honorable Hubert H. Humphrey, U.S. Senate. The Honorable Edward J. Thye formerly) U.S. Senate. The Honorable Walter H. Judd, ouse of Representatives. The Honorable Eugene J. McCarthy, House of Representatives (now U.S. Senator). The Honorable Joseph P. O’Hara, House of Representatives. The Honorable Roy W. Wier, House of Representatives. Advisers: Donald M. Alderson, colonel, USAF (MC), Office of the Assistant Secretary of Defense (Health and Medical). Ray Amberg, hospital administrator, University of Minnesota Hospitals, Minneapolis, Minn. ' Gaylord Anderson, M.D., director, School of Public Health, University of Minnesota, Minneapolis, Minn. Guillermo Arbona, M.D., secretary of health, Puerto Rico Department of Health, San Juan, RR. R. N. Barr, M.D., secretary and executive officer, Minnesota Department of Health, Minnea olis, Minn. Anon BlgfiS, chief, IDivision of Nursing, Ohio Department of Health, Colum- us, 10. Eugene P. Campbell, M.D., Chief, Public Health Division, International Cooperation Administration. H. Trendley Dean, D.D.S, secretary, Council on Dental Research, American Dental Association, Chicago, Ill. H5330? S. Diehl, M.D., vice president, American Cancer Society, New York, Charles L. Dunham, M.D., Director, Division of Biology and Radiation, Atomic Energy Commission. Herman E. Hilleboe, M.D., commissioner of health, State health department, Albany, N.Y. Charles A. Janeway, M.D., Thomas Morgan Rotch rofessor of pediatrics, Harvard School of Medicine, Harvard University, oston, Mass. Richard K. C. Lee, M.D., president, Board of Health, Honolulu, T.H. Phili E. Nelbach, executive secretary, National Citizens Committee for the W 0, Inc., New York, N.Y. Mrs. Owen B. Rhoads, Paoli, Pa. Rosbert O. Waring, Office of International Administration, Department of tate. Abel Wolman M.D., professor of sanitary engineering, Johns Hopkins School of Public Health and Hygiene, Baltimore, Md Laurence R. Wyatt, Oflice of International, Economic, and Social Afl’airs, Department of State. Secretary of delegation: Harry V. Ryder, J r., Office of International Conferences, Department of State. Press officer: Francis W. Tully, Jr., News Division, Department of State. Assistant press officer: J. Stewart Hunter, Assistant to the Surgeon General for Information, U.S. Public Health Service, Department of Health, Education, and Welfare. Administrative officer: Jacob Snyder, Office of Personnel, Department of State. Documents ofl-icer: Ellen M. Duggan, Office of International Conferences, Department of State. 92 UNITED STATES AND WORLD HEALTH ORGANIZATION Members of the stafl”: Mgry Jane Abboud, Office of International Conferences, Department of tate. MaurSeen S. Hannum, career development and counseling staff, Department of tate. Evelyn C. Harris, US. Public Health Service, Department of Health, Education, and Welfare. Medora M. Holm, correspondence review staff, Department of State. Dorothy Mead, Office of International Economic and Social Alfairs, Depart- ment of State. Yvonne T. Meuers, Office of Inter-American Regional Economic Affairs, Department of State. Evelyn R. Pope, Oflice of Near Eastern and South Asian Regional Affairs, Department of State. Mary E. Stratos, Office of the Assistant Secretary for Policy Planning, Department of State. Nora M. Walker, Foreign Service Institute, Department of State. US. delegation to the 12th World Health Assembly (Geneva, Switzerland, May 12, 1959) Delegates: Leroy E. Burney, M.D. (chairman); Surgeon General, Public Health Service, Department of Health, Education, and Welfare. Horace E. Henderson, Deputy Assistant Secretary, Bureau of International Organization Affairs, Department of State. Leonard Larson, M.D., chairman, board of trustees, American Medical Association. Alternate delegates: Lowell T. Coggeshall, M.D., dean, division of biological sciences, University of Chicago, Chicago, Ill. David H. Popper, Deputy US. Representative at the European Office of the United Nations and Other International Organizations, American Con- sulate General, Geneva. Ames C. McGuinness, M.D., Special Assistant for Health and Medical Affairs, Department of Health, Education, and Welfare. . Congressional advisers: Hon. John E. Fogarty, House of Representatives. Hon. Melvin R. Laird, House of Representatives. Advisers: Guillermo Arbona, M.D., secretary of health, Puerto Rico Department of Health, San Juan, P.R. H. M. Bosch, School of Public Health, University of Minnesota. ‘ George W. Dana, M.D., medical director, North Shore Hospital, Manhasset, Long Island, N.Y. Horace DeLien, M.D., Chief, Division of International Health, Bureau of State Services, US. Public Health Service, Department of Health, Educa- tion, and Welfare. D. G. Gill, M.D., president, Association of State and Territorial Health Ofl‘icers, State health ofl'icer, Alabama State Department of Health. Alfred Puhan, Office of International Administration, Department of State. James A. Shannon, M.D., Director, National Institutes of Health, US. Public Health Service, Department of Health, Education, and Welfare. Howard Sessions, captain, USN Bureau of Medicine and Surgery, Depart- ment of the Navy. Charles Williams, M.D., Deputy Chief, Public Health, International Co- operation Administration. Laurence Wyatt, Oflice of International Economic and Social Affairs, De- partment of State. Robert Yoho, M.D., director, health education, records, and statistics, Indiana State Board of Health. Richard C. K. Lee, M.D., president, Board of Health, Territory of Hawaii. UNITED STATES AND WORLD HEALTH ORGANIZATION 93 Members of the staff: John C. Grifl‘ith, American Embassy, Bern. Marvin Butterman, Geneva, Switzerland. Agnes Duer Escavaille, Geneva, Switzerland. Arleen Giglio, Geneva, Switzerland. Ethel Sempser, US. Public Health Service, Paris, France. B. LABORATORIES COOPERATING WITH WHO In addition to the voluntary services of individuals, laboratories as entities cooperate with WHO. This network of cooperating laboratories is beyond any doubt the most extensive linkage of medical and biological research facilities in the history of the world. One of the most recent tabulations (table 5—B) showed that more than 900 laboratories work cooperatively with WHO. These labora— tories are, of course, concentrated in countries whose scientific struc- tures are substantially developed. However, virtually every country in the world with any medical or biological research resources contains at least one laboratory which collaborates on WHO programs. For example, the Institut d’Hygiene Marcel Wanson in Leopoldville Belgian Congo, has played an active role in the WHO vector control and insect resistance program. The nature and purposes of laboratory cooperation with WHO are as broad as the WHO disease control, training, and research programs. Without attempting to be comprehensive, the kinds of functions performed by the cooperating laboratories are set forth below: TABLE 5—B.—Instttutions and laboratories closely related with the work of WHO Institutions and laboratories undertaking some research at the request of WHO, without receiving grants, in each of the following fields: Veterinary public health ________________________________________ 122 Zoonoses _____________________________________________________ 3 Rabies _______________________________________________________ 6 Brucellosis ____________________________________________________ 14 Malaria ______________________________________________________ -34 Endemo-epidemic diseases ______________________________________ 40 Biological substances ___________________________________________ 81 Trachoma ____________________________________________________ 13 Leprosy ______________________________________________________ 11 Onchocerciasis ________________________________________________ 53 Poliomyelitis __________________________________________________ 17 Influenza _____________________________________________________ 61 Hepatitis _____________________________________________________ 28 Yellow fever __________________________________________________ 14 Diptheria/pertussis ____________________________________________ 15 Typhoid vaccine _______________________________________________ 4 Specification and methods of assay of pharmaceutical preparations- _ 41 Tuberculosis __________________________________________________ 52 Vector control and pesticides ____________________________________ 21 Resistance of insects to insecticides ______________________________ 119 Nutrition _____________________________________________________ 3 Social and occupational health __________________________________ 1 Mental health _________________________________________________ 3 Venereal diseases and treponematoses laboratories _________________ 55 Total ______________________________________________________ 81 1 94 UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE 5—B.—Institutions and laboratories closely related with the work of WHO—- Continued Institutions and laboratories which have been designated by WHO to undertake international responsibilities in health fields such as reference laboratories and WHO centers: International centers for biological standards ______________________ International reference laboratories, sera and cultures ______________ WHO influenza centers _________________ ' ___________________ 5 WHO regional poliomyelitis centers _____________ Venereal disease reference laboratories and centers- WHO/FAQ leptospirosis reference laboratories _____ FAO/ WHO brucellosis centers ________________________________ 1 Grand total _________________________________________________ 906 Functions include— (1) Collection of biological material; isolation and identification of viruses and other organisms as part of worldwide networks. (2) Conduct of research as part of a coordinated international research program. (3) Serving as sites for field study headquarters. (4) Providing facilities for training of professional and auxiliary personnel from other countries in specific laboratory methods or research procedures. (5) Provision of facilities for conduct of coordinated interna- tional field trials of vaccines or other material for preventing or treatin disease. (6) cting as centers for statistical analysis of observations gathered over wide geographical areas. (7) Preparing standardized sera and cultures for worldwide use. (8) Conduct of research directly related to WHO disease control programs. (9) Serving as centers for preparation and distribution of standardized biological reference material. Collaborating laboratories in United States While the number of laboratories in the United States which col— laborate with WHO fluctuates as programs change, a recent count showed that about 175 to 200 scientific organizations—academic, industrial, and governmental—participate in one way or another in WHO activities. The collaborating laboratories range from coast to coast and from Alaska to Texas. Thus, the medical schools of Yale University and the University of California have been particularly active in relation to WHO programs; both the Arctic Health Research Laboratory of the Public Health Service in Anchorage, Alaska, and the Laboratory of Medical Entomology of the University of Texas work with the World Health Organization. The collaborating laboratories perform for WHO all of the functions noted above, and in addition they are an important source of expert advice to WHO. Indeed it is safe to say that most, if not all, of the outstanding U.S. experts in fields of medicine, public health, and research that have been of particular interest to WHO have aided the programs of the organization in one way or another. UNITED STATES AND WORLD HEALTH ORGANIZATION 95 Collaborating organizations include academic, governmental, and industrial laboratories. Illustrative examples of each are as follows: 1. Federal laboratories (a) Department of Health, Education, and Welfare: US. Public Health Service: Arctic Health Research Center, Anchorage, Alaska: Zoo- notic Disease Section. Communicable Disease Center, Atlanta, Ga.: Virus and Rickettsia Section (Dr. M. Schaefler). Rocky Mountain Laboratory (Dr. C. A. Larson). National Institute of Allergy and Infectious Diseases: Laboratory of Infectious Diseases (Dr. K. Habel). Laboratory of Tropical Diseases (Columbia, SC.) (Dr. M. D. Young). (b) Food and Drug Administration: Antibiotics Laboratory (Dr. H. Welch). , (c) Department of Agriculture, Agricultural Research Services: Beltsville, Md.: Animal Disease Section. Entomology Research Branch. Orlando, Fla.: Entomology Research Branch. (03) Department of the Army: Chemical Corps Medical Research Directorate: Ento— mology Branch. Quartermaster Research and Development Laboratories: N atic Mass: Vector control and Resistance (Dr. J. J. Pratt). Walter Reed Army Institute of Research (Dr. M. R. Hilleman). (e) Department of the Navy: Preventive Medicine Division (Cmdr. K. L. Knight). 2. Academic laboratories (including hospital laboratories) (a) Children’s Hospital, Cincinnati: Research Foundation (Dr. A. B. Labin). (b) Children’s Hospital, Boston (Dr. J. F. Enders). (0) Cornell University, New York: Department of Public Health and Preventive Medicine (Dr. W. McDermott). (d) Johns Hopkins University, Baltimore, Md.: School of Public Health, Department of Microbiology (Dr. T. B. Turner). (e) Ohio State University, Columbus, Ohio: Department of Zoology and Ecology (Dr. F. W. Fisk). Missouri Trachoma Hospital, Rolla, Mo.: Research Division (Dr. A. A. Siniscal). (g) Purdue University, Lafayette, Ind.: Biophysical Laboratory (Dr. L. J. Mullins). (h) University of Minnesota, School of Medicine: Department of Bacteriology (Dr. J. T. Syverton). School of Public Health (Dr. G. Anderson). (73) University of Pittsburgh: School of Medicine (Dr. J. E. Salk). Graduate School of Public Health, Department of Epi- demiology and Microbiology (Dr. W. McD. Hammond). (7') University of Texas: Department of Preventive Medicine (Dr. D. W. Micks). 96 UNITED STATES AND WORLD HEALTH ORGANIZATION 3. Industrial laboratories (a) Lederle Laboratories Division, Pearl River: Section on Viral and Rickettsial Research. (6) Lilly Laboratory for Clinical Research, Indianapolis: Clinical . Research Division (Dr. E. B. Peck). (c) E. B. S uibb and Sons: Squibb Institute for Medical Research (Dr. 3. T. Culbertson). 4. State laboratories California State Department of Health: Division of Laboratories (Dr. E. H. Lenette). - New York State Department of Health: Division of Laboratories and Research (Dr. M. M. Pangborn). C. COORDINATION WITH U.N. ORGANIZATIONS The importance of the coordination of the activities of WHO with programs of other organizations derives from the fact, as previously pointed out, that health generally forms an integral part of country and regional programs of development. Such coordination, therefore, has to extend not only to the United Nations and its specialized agencies but, equally, to regional intergovernmental organizations, to bilateral programs of assistance, and to nongovernmental organizations which are active in social, health, and related fields. Coordination is especially important because limited resources are available for inter- national health activities. . This section is devoted to those aspects of coordination that are of special interest to the subcommittee. 1. Economic and social council The primary responsibility for the coordination of the programs of the United Nations and the specialized agencies is vested in the Eco- nomic and Social Council. It is assisted in this task, at the inter- secretariat level, by the Administrative Committee on Coordination comprising the Secretary-General of the United Nations and the executive heads of the agencies. In addition to the agreement in terms of which WHO was brou ht into relation with the United Nations as a specialized agency, W O has also entered into agreements with the International Labour Organ- ization (ILO), the Food and Agriculture Organization (FAO), and the United Nations Educational, Scientific and Cultural Organization (UNESCO). These agreements provide for cooperation and con- sultation between the organizations on all matters of common interest. Furthermore, bilateral cooperation on a practical basis has been de- veloped between the secretariat of WHO and of each of the other organizations, including those with whom WHO has no formal agree- ments. - A special clause of the a reement between WHO and the United Nations provides that WH shall participate in and cooperate with any body set up by the Economic and Social Council for the purpose of facilitating coordination of the activities of the specialized agencies. Other articles in the agreement relate to the assistance to be ren- dered by WHO to the Security Council and the Trusteeship Council, and also with regard to non-self-governing territories, on matters Within its competence. UNITED STATES AND WORLD HEALTH ORGANIZATION 97 Within this framework WHO has reported each year to the Eco- nomic and Social Council and has participated in a number Of activities common to the United N al-ions and several specialized agencies. These functions have included the preparation of reports on the world social situation, the development of international social programs, and OI'cOhceTIEd’practical action in the social field, including long-range activities for children, rehabilitation of the physically handicapped, family levels of living, etc. Perhaps the most efl’ective way to show the nature and extentof this cooperation is to cite some Of the actual working relationships with the UN. specialized agencies established by the operating divisions of the World Health Organization. Multiple eflorts.—One Of the characteristics Of the Operation Of U.N.’s specialized agencies is cooperation among a group of agencies to solve problems requiring a wide range of skills, contacts, and resources. As an example, a technical working group on long-range activities for children was established in 1951 by the United Nations Adminis- trative Committee on Coordination. It met in 1951, 1952, 1954, and 1956, and included representatives Of the United Nations, UNICEF, ILO, FAO, UNESCO, and WHO. The group has dealt with such matters as child nutrition, the extension of free and compulsory education, assessments of children’s services and the care of children deprived Of normal homelife. The needs of the physically handicapped child were studied in 1951 by a group of experts convened by WHO with the participation Of the United Nations, ILO, and UNESCO. Several countries have been assisted with programs based on the recommendations and principles formulated by this group. Programs for the organization and staffing Of rehabilitation services for handicapped children have received assistance from WHO and UNICEF over a number of years in Austria, Greece, Italy, and Yugoslavia, to which the United Nations, ILO, UNICEF, and WHO have jointly sent consultants. A study group on the child with impaired hearing was organized by WHO in 1955 in cooperation with the United Nations, UNESCO, and IL0. Its findings are in the process of being published. A representative of WHO regularly attends the biennial sessions of the Technical Advisory Committee of the International Children’s Center. Other members are the Director General of the center, and representatives of the United Nations Technical Assistance Adminis— tration, UNICEF, ILO, FAO, and UNICEF. The center, which was established in 1947, has devoted itself primarily to the following activities: international teaching of child welfare problems (in which WHO has participated), medical social research work, international documentation and publications, and international cooperation in matters of child welfare. ‘ WHO deals generally with UN. on broad social programs which include the field of community development, urbanization, housing, water resources and family levels of living. As far as the specific fields are concerned, PHA handles directly the community develop- ment programs. The UN. and the specialized agencies have agreed to take community development programs as a field for concerted action. Examples of such programs operating are the local health service 98 UNITED STATES AND WORLD HEALTH ORGANIZATION projects in India and Afghanistan and the provincial (or liwa) health service in Iraq. As a final example, the organization is participating in the U.N. Andean Indian program by assigning a medical officer to assist the Governments of Bolivia and Peru in establishing health services and training local auxiliary personnel. 2. UNI C'EF (United Nations Children’s Fund) WHO—UNICEF relationships are extremely close, as indicated by the fact that in 1959 they will cooperate in more than 200 joint projects (table 5—C). Nutrition programs.——Three kinds of WHO nutrition programs are carried out jointly with UNICEF. FAO also takes an important part in these. Supplementary feeding programs.—Assistance to governments in planning and developing supplementary feeding programs for mothers and children is given through UNICEF, which supplies large quantities of skim milk in many parts of the world. An indication of the scope of recent UNICEF aid is given in the following table: Skim milk powder shipped by UNICEF [In tons] 1955 1956 1957 ’ Feeding through maternal and child welfare centers ........... 35,000 43, 000 42, 000 ' Emergency feeding ........................................... 21,000 27, 000 1, 500 Total ................................................... 56, 000 70, 000 43, 500 An evaluation survey is at present being carried out by a WHO— FAO team in order to assess the magnitude of the results. Policy on new sources of protein-rich foods.—As previously pointed out, the long-term improvement in child nutrition, particularly in developing countries, depends primarily on measures taken within the country to increase the production of foods rich in proteins. Such measures must be associated of course, with an education program. Where protein malnutrition is caused by the inability of the people to obtain a suitable protein-rich food, the solution must lie in finding a cheapsource of such food. In 1952, 1953, and 1954, WHO made grants to three research centers in east Africa, Guatemala, and south India to assist them in investigating the suitability of vegetable protein from different sources for the prevention of protein malnutri- tion. Due to the fact that the safety and suitability of any food is a highly specialized matter, WHO appointed a small protein advisory group, which is working in close association with UNICEF and FAQ. Three pilot plants have been set up by UNICEF in order to produce these new protein foods: Fish flour in Chile, saridele (soya) in Indo— nesia, and peanut meal in Nigeria. (The latter was approved by the UNICEF Executive Board in September 1958.) This policy complements the VVHO—FAO UNICEF programs di- rected towards increasing the supply of milk wherever possible. Expanded aid to maternal and child nutrition—After an extensive intersecretariat consultation between UNICEF, FAO, and WHO, the UNITED STATES AND WORLD HEALTH ORGANIZATION 99 UNICEF Executive Board, in September19 57, approved the formu- lation of a new program known as expand ed aid to maternal and child nutrition. It emphasizes nutrition programs designed to be effective at the village level and to stimulate self-help activities so that rural families can make the best use of locally available and potential food resources. This program is under the auspices of UNICEF, but is ad- ministered with the help of technical advice from WHO and FAQ. It includes the following: Training in nutrition of national personnel, edu— cation in nutrition, practical demonstration projects at the village level concerned with such activities as school gardens, fish culture, small animal raising, home food preservation and storage. Also included is limited “Vltamin supplementation” directed against endemic de- ficiency diseases which seriously affect children and pregnant and nursing women. ' At present five'c ountries have received aid from UNICEF in this new program. 3‘ It is interesting to note that of UNICEF allocations foreseen for the next 3 years, those relating to all nutrition activities will rise from $5.3 million in 1959, to $6.4 million in 1961. , Maternal and ‘child health programs—Most of the assistance to governments in the field of maternal and child health has been given jointly by WHO and UNICEF, with WHO responsible for providing professional staff, technical guidance and fellowships for professional training, and UNICEF the necessary equipment, supplies, transport, and training stipends for local auxiliar personnel. An example of training activities whic may be cited is the assistance given by WHO and UNICEF to the department of maternal and child health of the All-India Institute of Hygiene and Public Health, Calcutta. For it, at various times since 1953, there has been provided a pediatric nursing instructor, an administrative officer, a specialist in social medicine, .a pediatrician, and a health educator. Post- graduate public health training was introduced, a child health and child guidance clinic was set up at the rural health center at Singur and training at the center improved, and an urban pilot health center was started in Calcutta. The institute is now training students from a number of countries in Asia. During the first years, WHO, besides helping to train personnel, assisted many countries to organize in selected areas demonstration and training projects, to which UNICEF often contributed equip- ment and supplies. With their national counterparts, WHO personnel assigned to these projects aimed at demonstrating modern methods and training local staff in the necessary technique. In Kabul, Afghanistan, for instance, WHO assisted in the establishment of a modern maternity hospital, a modern pediatric ward, a domiciliary midwifery service, and several antenatal and child welfare clinics. Trained midwives gave service for the first time in the history of the country. The most important result of projects of this nature was that they provided large numbers of trained health workers and that some of them became the starting points of more comprehensive local health services. Two reviews of WHO—UNICEF assistance in maternal and child health have been carried out by headquarters staff. The last one, ' entitled “Review of Maternal and Child Health Activities and Related Training of Professional and Auxiliary Health Workers,” was pre- 100 UNITED STATES AND WORLD HEALTH ORGANIZATION sented to the Joint WHO—UNICEF Committee on Health Policy in 1957. The subject of the study to be presented to the JCHP in 1959 will be on MCH centers in each region, with particular attention to the extent to which child care and nutrition are incorporated in the program. 3. FAO (United Nations Food and Agriculture Organization) Nutrition programs—The Nutrition Section of WHO and the Nutri- tion Division of FAO have established close contacts since 1949. Joint expert committees on nutrition.——Five joint FAQ/WHO expert committees on nutrition have been held in the following years: 1949, 1951, 1952, 1954, and 1957. It is envisaged that the sixth session Will be in 1960. The terms of reference of the Committee have been established as follows: (1) To advise the Directors General of FAO and WHO on the problems of nutrition which might receive the attention of the two organizations and to assist in coordinating their respective programs in this field, and (2) to advise either Director-General or both on any technical problems concerned with nutrition which they may submit to it. Regional nutritional conferences—FAQ and WHO have sponsored re ional nutritional conferences to which governments have sent de egations to discuss their problems. These conferences have been of value both to the countries and to the international agencies, for through them there has been a two-way flow of information. Much of the work on nutrition in the regions has originated from them; There have been four such conferences in southeast Asia and also four in Latin America. In Africa, the Commission for Technical Cooperation in Africa south of the Sahara (CCTA) has organized three conferences of the same kind, in which FAO and WHO have taken part. , Special meetings and seminars have also been organized by FAO and WHO for specific purposes in different parts of the world. For example, an interagency workin group on milk and milk products, composed of representatives of TAO, UNICEF, and WHO, met at WHO headquarters in March 1958 to discuss plans for milk surveys to be undertaken jointly by the three organizations. The surveys are to be conducted in countries which request international aid in developing dairy production, stimulating milk consumption, and in initiating measures for using surplus dairy products. Nutrition training eourses.—Four nutrition training courses have been organized jointly by FAO and WHO—one in Cairo (1950), two in Marseilles (1952 and 1955) and one in Kampala, Uganda (1957). Joint FAO/WHO surveys in nutrition—Various FAQ/WHO surveys of protein malnutrition have been made in Africa, Central America, and Brazil. Besides these, several countr surveys have been under- taken jointly by WHO and FAQ in Cey on, Ethiopia, Burma, and Ghana in the last 2 years. In general it can be said that WHO collaborates closely with FAO in all nutrition programs. While WHO is primarily concerned With nutrition as it affects health, the objectives of FAO are to raise levels of nutrition and standards of living and to improve the efficiency of the production and distribution of all food and agricultural products. UNITED STATES AND WORLD HEALTH ORGANIZATION 101 4. UNESCO (United Nations Educational, Scientific and Cultural 0r~ ganieation) The relationships of WHO with UNESCO are varied, and arise from the interrelated nature of many programs of both agencies. As a delegate to the UNESCO Conference in Paris, in October 1958, I was able to note these relationships at first hand. UNESCO and WHO have jointly sponsored the Committee for International Organizations of the Medical Sciences (CIOMS), a group devoted to the improvement of international communication in the medical sciences. While in Paris, I conferred, among others with Dr. J. F. Delafrasnaye, executive secretary of CIOMS. WHO cooperated with UNESCO in the Joint Expert Committee on the Physically Handicapped Child, 1951, and in the study group on the child with impaired hearing, 1955. WHO was represented at the second and third sessions of the International Advisory Committee on the School Curriculum. Interest in the work of this committee is a result of the joint activites of the health education and MCH sections on health education in schools. A study guide on teacher preparation for health education was prepared jointly by WHO and UNESCO. The Organization, because of its interest in school health, was also represented at the 21st International Conference on Public Educa- tion, organized by UNESCO and the International Bureau of Educa- tion in Geneva in 1958. 5. ILO (International Labor Organization) The responsibilities and interests of WHO and IL0 meet at many points. ILO is interested in the total welfare of laboring peOple (including their health), While WHO is interested in the health of people (including special conditions affecting workers on the job). These common interests give rise to numerous cooperative efforts: The social and occupational health activities of WHO are related ‘ closely with ILO in many fields, namely, occupational health, social security, and financial aspects of medical care, hygiene of seafarers, rehabilitation, and migration. In these fields many joint expert com- mittee and ad hoc technical working group meetings have taken place between ILO and WHO since the beginning of the Organization. Technical conferences, seminars, symposia, etc., have been held in the field with both organizations participating. Similarly, nurses from WHO have worked closely with the nursing consultant of ILO in the preparation of a report on employment con- ditions of nurses. This report has now been considered by an ad hoc committee. Helpful recommendations are expected to be presented to the ILO governing body. Other U.N. agencies are as follows: 6. United Nations Relief and Works Agency (Arab refugees) (UNR WA) WHO provides the chief medical officer and technical advice to UNRWA. An important task undertaken by the Nutrition Section of WHO is to assist UN RWA in carrying out continual assessments of the nutritional status of the Palestine refugees. Limited rations ’ are supplied but a high proportion of these large populations have some facilities for supplementing them. These facilities, however, differ considerably in different areas and at different times. There is, therefore, a need for careful periodic check on the health of these 102 UNITED STATES AND WORLD HEALTH ORGANIZATION people. A number of visits have been paid by staff of the WHO Nutrition Section to UNRWA and extensive clinical examinations have been made. 7. UN. Department of Economic and Social Afiairs WHO has a working relationship with the Bureau of Social Aflairs of the United Nations Department of Economic and Social Affairs in the Fields of medical rehabilitation, medicosocial work and the costs and finance of medical care. There are routine as well as special con— sultations on professional and administrative aspects of joint field projects, for example in rehabilitation. In addition, interagency tech- nical working groups may from time to time be convened to discuss problems of mutual interest. 8. UN. narcotics control A number of international conventions on the control of narcotic drugs provide for the Director—General’s taking decisions, on the basis of appropriate expert advice, with regard to the status of drugs under . the international control provisions. Apart from that, WHO acts as adviser on the medical aspects of drug addiction and addiction- producing drugs to the United Nations’ organs concerned, i.e., the Economic and Social Council, its Commission on Narcotic Drugs with the Division of Narcotic Drugs as Secretariat, the Permanent Central Opium Board, and the Drug Supervisory Body. The value of the existing close collaboration of WHO with the aforementioned bodies may be seen from the 1958 motion of the Commission on Narcotic Drugs: To pay high tribute to\ the important contribution which WHO, and particu- larly its Committee on Addiction-Producing Drugs, continues to make to the international control of narcotic drugs. . The work leading to this section was outlined in part IV above, dealing with the development of WHO’S research program. .9. The need for constant review of jurisdictional lines It is clear from the preceding illustrations that the intergovern- mental organizations—notably UNICEF, FAO, ILO, and UNESCO—— share many interests ‘in common with WHO. Under the circum- stances, there must be constant reevaluation of what is the proper role that each organization should play, in relation to one another. This is especially true because the responsibility of each organiza- tion changes with changing times and needs. Jurisdictional lines between the organizations which might not have been wholly exact, even when originally laid out, have often tended to become blurred even further over a period of years. It is a fact familiar to students of public administration that it is a tendency of organizations to maintain themselves in some activities long after circumstances require adaptation along new lines. For- tunately, the World Health Organization has, by and large, sensed the need for new patterns of activity. It is less clear that some of the other international organizations have always actually worked out with . WHO new relationships to define necessary changes in jurisdiction. A constant effort must therefOre, be made by the policymaking bodies of 'the intergovernmental organizations, and by their secretariats, to reappraise objectively what the optimum jurisdictions and inter—_ relationships should be.. UNITED STATES AND WORLD HEALTH ORGANIZATION 103 10. Cooperation on radiation problems The newer the field and the greater the challenge, the more essential it is that there be a maximum of efficiency in the work of the specialized agencies and in their liaison with one another. The point is made throughout this report that there are few, if any, fields in which such efficiency and liaison are more necessary than in the appraisal of the effects of ionizing radiation. The world cannot be satisfied with the sum total of knowledge thus far available throu h all the many agencies concerned with this question. More fruitfu work by each of these agencies, individually and in collaboration, is essential. WHO has a particular responsibility, as has the United Nations Committee on Effects of Radiation and the International Atomic Energy Agency, to name but three of the most concerned groups. WHO has begun to meet this challenge. In 1955, an expert was appointed to the staff of WHO to advise the Director General on atomic energy in relation to health. Later that year, WHO in collaboration with the Government of Sweden and the Atomic Energy Commission of the United States of America, sponsored the first international course for health physicists ever to be held. This was followed by another course in Belgium in 1957, and in the United Kingdom and France in 1958. The Ninth World Health Assembly (1956) had already asked the Director General to warn all member states that the planning and execution of any project for the peaceful use of atomic energy should be done in close contact with public hefiilth authorities. The present program of WHO in this field is as o ows: 1. Training for three distinct categories of workers: specialists for protective work in atomic energy laboratories or plants (normally either physicians or “health physicists”); public-health administra- tors, who would be particularly interested in such questions as the disposal of radioactive waste and the siting of reactors; and medical uses of radioisotopes. 2. Collection and distribution of information on the medical problems of atomic energy and on the medical uses of radioisotopes. 3. Study of the health problems involved in the location of reactors and in the disposal of radioactive waste from factories, laboratories, and hospitals. . 4. Cooperation with the competent technical bodies on the standard- ization of radiation units, on codes of practice such as the recommenda— tions of the International Commission on Radiological Protection; and on the pharmaceutical specifications of methods of preparing radiOsotopes for medical use. 5. Coordination of research on the health aspects of radiation. This report cannot attempt to analyze the many implications of the radiation problem. Suffice it to say that I know of no scientist who is not convinced that the world is at present tragically deficient in some of the most elementary information bearing upon the effects of radiation. WHO is ideally suited among other purposes to spearhead the further collection of epidemiological information. One of the best illustrations is in connection with WHO’s interest in those unique geographic areas where substantial populations have long since been exposed to continuous doses of relatively high radiation from natural sources for long periods of time. Such a situation exists in the southernmost regions of the west coast of India, in parts of / 104 UNITED STATES AND WORLD HEALTH ORGANIZATION Kerala and Madras states. Here, it is presumed, can and will be obtained indispensible information of the following types: 1. Essential demographic statistics, such as calculated birth rate, life expectancy, ratio between sexes. 2. Data on human growth and development. 3. Patterns of congential defects. 4. Patterns of morbidity and mortality. 5. Laboratory studies on blood groups, hemoglobin, and other genetic markers. 6. Post mortem studies. 7. Correlative studies on plant and animal material. The availability of such knowledge can, and no doubt will, have immense significance to world science as well as to political decisions in the future. ‘ D. COOPERATION WITH INTERNATIONAL PROFESSIONAL ORGANIZATIONS Over the years, groups and individuals in various countries who are linked by common interests have banded together in unofficial but influential international organizations. Many of these are related to health—such as those having to do with medical practice, medical care, hospital administration, nursing, various areas of medical research, and various scientific disciplines. These organizations and WHO supplement each other. The pro- fessional organizations are an indispensable means of international communication. The WHO has official relationships with govern- ments, and Often more extensive resources than the private organiza— tions. Extensive cooperative relationships have evolved so that each may share the strengths of the other. A few examples of cooperative relationships will be presented. A complete list of the nongovernmental organizations in official relation- ship with WHO will follow shortly (table 5~C). Future reports by this subcommittee will include more detailed references to the very constructive work of organizations, which are not cited, for purposes of brevity, in the illustrations which follow. The forthcoming publications will refer, for example, to International Red Cross work, to the activities of the World Veterans’ Federation, of the Inter—American Association of Sanitary Engineering, the Inter— national Conference of Social Work, the International Society for the Welfare Of Cripples, and the World Federation of United Nations Associations. All of these groups have favored the subcommittee with helpful reports. TABLE 5—C.—Nongovernmental organizations in ofiicial relationship with the World Health Organization Biometric Society, Rathamsted Experiment Station, Harpenden, Herts, England; secretary, J. J. R. Healy. Central Council for Health Education, 92, Rue Saint-Denis, Paris Ier, France; secretary general, Dr. Lucien Viborel. Council for International Organizations of Medical Sciences, 19, Avenue Kléber, Paris 166, France; secretary, J. F. Delafresnaye. Federation Dentaire Internationale, 35, Devonshire Place, London, W. 1; sec- retary general, G. H. Leatherman. Inter—American Association of Sanitary Engineering, Alfonso Herrera 11-103, Mexico 4, DE; secretary general, Francis W. Montonari, Ohio River Valley Water Sanitation Commission, 414 Walnut St., Cincinnati 2, Ohio. UNITED STATES AND WORLD HEALTH ORGANIZATION 105 International Academy of Legal Medicine and of Social Medicine, Via De Toni, 12, Genes, Italy; secretary general, Prof. G. Canepa. International Association of Microbiological Societies; secretary general, Prof. G. Penso, Casella Postale 7078, Rome. International Assoeiation for the Prevention of Blindness, 47, Rue de Bellechasse, Paris 7e; secretary general, J. P. Bailliart. ’ International Commission on Radiological Protection, Radiological Protection Service, Downs Nursery Hospital, Cotswold Road, Sutton, Surrey, England; secretary general, W. Binks. International Commission on Radiological Units and Measurements, Radiological Protection Service, Docons Hospital, Cotswold Road, Sutton, Surrey, Great Britain, secretary; Mr. Walter Binks. International Committee of Catholic Nurses, 16, Rue Tiphaine, Paris 15a; secretary general, Mademoiselle Callou. \ International Committee of the Red Cross, 7, Avenue de la Paix, Geneva; presi- dent, Léopold Boissier. International Confederation of Midwives, care of the Royal College of Midwives, 1537, Lower Belgrave Street, London, SW. 1; executive secretary, Miss Marjorie aves. International Conference of Social Work, 345 East 46th St., New York 17, N .Y.; secretary general. Joe R. Hofier. International Council of Nurses, 1, Dean French Street, Westminster, London, SW. 1; executive secretary, Mlle D. C. Bridges. International Diebetes Federation, 33 Prinsegracht, The Hague, Netherlands; executive secretary, P. Duys. International Federation of Gynecology and Obstetrics, Maternité, Rue Alcide Jentzer, Geneva; secretary, R. Keller. International Federation for Housing and Town Planning, 123, Loan Copes van Cattenburch, The Hague; secretary general, H. Van der Weijde. International Hospital Federation, 10, Old Jewry, London, E.C. 2; secretary general, J. E. Stone. International Hydatidological Association, (International Society of Hydatidosis), Canelones 1280, Montevideo; secretary, Alfredo Ferro. International League Against Rheumatism, care of Dr. R. T. Smith, secretary treasurer, Dr. R. T. Smith, West Point, Pa. International Leprosy Association; Secretary treasurer, Dr. E. Muir, 8 Portman St., London, W. 1. International Organization Against Trachoma, 94, Rue Sylvabelle, Marseille, France; Secretary General, Jean Sédan. International Paediatric Association; Secretary General, Prof. G. Franconi, Kinderspital, Steinwiesstr. 75, Zurich 32, Switzerland. International Pharmaceutical Federation; secretary general, Dr. J. W. Birza, 196, Bilderdijkstraat, Amsterdam. International Society for Blood Transfusion, 57, Boulevard d’Antenil, Boulogne- sur—Seine, France. International Society for Criminology; secretary general, Jean Pinatel, 28, Avenue de Friedland, Paris, 8e, France. International Society for the Welfare of Cripples, 701 First Avenue, New York 17, Y.; secretary general, Donald V. Wilson. International Union Against Cancer, 25, Rue d’Ulm, Paris, 5e, France; secretary general, Dr. Harold F. Dorn. International Union for Child Welfare, 1, Rue de Varembé, Geneva; secretary general, D. Q. R. Mulock Houwer. International Union for Health Education of the Public, 92 Rue Saint-Denis, Paris ler; secretary general, Dr. Lucian Viborel. International Union Against Tuberculosis, 15 Rue Pomareu, Paris 16e; secretary general, Etienne Bernard. International Union Against Venereal Diseases and the Treponematoses, Institut Alfred Fournier, 25 Boulevard Saint-Jacques, Paris He, ,France; secretary general, A. Cavaillon. Leggue 01ft Red Cross Societies, 40 Rue du 31 Décembre, Geneva; secretary general, . de ougé. Medical Women’s International Association, in care of Dr. Janet K. Aitken, honorary secretary, 30a Acacia Road, London, N.W. 8, England. 38516—59—8 106 UNITED STATES AND WORLD HEALTH ORGANIZATION World Confederation for Physical Therapy, in care of Dr. P. Bauwens; honorary secretary, 45 Lincoln’s Inn Fields, London, W.C. 2. World Federation for Mental Health, 19 Manchester Street, London, W. 1; secre— tary general, Miss E. M. Thornton. World Federation of Societies of Anaesthesiologists, 17 Burghley Road, Wimble- don, London, SW. 19, England; secretary-treasurer, Dr. G. S. W. Organe. World Federation of United Nations Associations, 1, Avenue de la Paix, Geneva, Switzerland; vice president, Lue de Meuron. ' World Medical Association, 10 Columbus Circle, New York 19, N.Y.; Dr. Louis H. Bauer, secretary general. ' World Union OSE (Child Relief and Health Protection Of Jewish Populations), 18, Rue Volney, Paris, 2e; director, A. Gonik. World Veterans Federation, 27, Rue de la Michodiere, Paris, 2e; president, Albert Moral. Examples of cooperative relationships with WHO In relation to international efforts to aid children, WHO made a grant to the International Pediatric Association for a study Of pedi— atric education in Europe. This study, plus information later col— lected during surveys of pediatric education in Australia, New Zea- land, and Latin America, served as a basis for the work of the Stud Group on Pediatric Education which met in Stockholm in 1956. t discussed the objectives of pediatrics in medical education, the con- tent of teaching in pediatrics, and the teaching methods likely tO be successful under different circumstances. The Organization assisted the International Union for Child Welfare in 1955 with a study Of the needs of children and the future role of the IUCW. Statements were contributed to the Union for World Children’s Day 1957 and 1958. WHO was represented at the World Child Welfare Congress in Brussels in July 1958. The theme of this Congress—“The Parents’ Role in the Child’s Development”—~ has many implications for WHO in view of the whole question of parents’ relations with health services. As part of the WHO program relating to communicable diseases, WHO cooperates in program formulation with the International Union Against Venereal Diseases and Treponematoses, which holds official relationship status with WHO. The regional Office for the Americas Of this organization is located in New York. The American Social Hygiene Association, the subcommittee has found, is one of the many voluntary health organizations which has demonstrated a very deep interest in international problems. In the infectious disease field, WHO is also in Official relations with the International Organization Against Trachoma, the International Organization for Prevention of Blindness, and the International Leprosy Association. ' The latter was admitted into Official relationship with WHO in 1951, and has closely collaborated in the development of various activities of the WHO leprosy control program. Various members have been appointed as members of the WHO Expert Advisory Panel on Leprosy, participating at the expert committee meetings, or acting as WHO consultants to advise requesting members states. WHO has assisted ILA in organizing the VI and VII International Congresses of Leprology (Madrid 1953, Tokyo 1958). The organization Of the latter has been coordinated with the WHO Interregional Leprosy conference for southeast Asia and Western Pacific areas of endeinicity. Finally, either through official relationships, by personal contact or through the intermediary of the directors of WHO international cen- UNITED STATES AND WORLD HEALTH ORGANIZATION 107 ters, WHO cooperates with the International Association of Micro— biological Societies With the object of collecting and exchanging inforg mation on laboratory procedures. Cooperation between WHO and the World Medical Association is close and diversified. For example, WHO is cooperating With and giving financial assistance to the World Medical Association in the World Conferences on Medical Education of which the second will be held in Chicago in September 1959. Contacts with the Association have also been maintained in connection with the selection of drugs for inclusion in the International Pharmacopoeia. Lists of what is included in volumes I and II of the International Pharmacopoeia (first edition) already printed and the supplement to these two vol- umes now with the printers, were submitted for comments. The World Medical Association forwarded these lists to their national medical associations and returned them to WHO with the comments received. In the United States, the American Pharmaceutical Manu— facturers Association cooperated along this line. This will be done a ain for the list of drugs to be included in the second edition. Tables 0 posology for adults and children, which have been published in volumes I and Hand prepared for the supplement have also been submitted for comments on the same basis as above. The comments received have been integrated into the final text of these tables. It is intended to obtain similar information from the World Medical Association and the national medical associations for all details on posology to be included in the second edition of the International Pharmacopoeia now in preparation. Dr. Louis Bauer, a past presi— dent of the American Medical Association, is Secretary General of the World Medical Association. The significance of this vital organi- zation and of its relationship with WHO can hardly be overestimated. The International Council of Nurses is the international body with which the American Nurses Association and other nursing associa- tions are affiliated. World Mental Health Y ear A most interesting illustration of resoursefulness and initiative is the observance in 1960 of ,World Mental Health Year. This inter- national activity is under the auspices of the World Federation for. Mental Health with the cooperation of governmental and nongovern- mental organizations. The concept of designating 1960 as World Mental Health Year arose from a suggestion made in August 1957 by 'Dr. Frank Fremont-Smith, a past President of the Federation. After consulting carefully with the WHO and with its affiliated asso— ciations and societies in 43 countries, officials of the Federation decided to go ahead with the plans. , It might be of interest to note the general aims of the World Fed- eration itself: To promote among all peoples and nations the highest possible Standard of mental health, in its broadest biological, medical, educational, and social aspects; To foster the ability to live harmoniously in a changing environment; to make recommendations, and promote and encourage research in the field of mental health; 108 UNITED STATES AND WORLD HEALTH ORGANIZATION To promote cooperation among scientific and professional groups which con- tribute to the advancement of mental health, and to encourage the improvement of standards of training in the relevant professions. My conferences with _Dr. Fremont-Smith and with Dr. J. R. Rees, Director of the Federatlon and also a past President, impress me with the worthwhileness of the ploneerlng endeavor of the year. International Dental Federation WHO has collaborated with the International Dental Federation. Since the latters founding in 1948, observers have been sent to each other’s meetings, continual contact has been maintained and advice exchanged. Many Federation oflicers and members have taken part in WHO expert committees and study groups on dental subjects. Finally, relationships between WHO and the International Union Against Cancer are quite close. The Union is aiding WHO in the preparation of an international program for cancer research; scientists active in the Union are serving as consultants to WHO in framing the details of a program. A future publication by this subcommittee will document the leading role which has been played in the world cancer effort by the American Cancer Society. As a result of the network of personal and official relationships arising from all of these cooperative efforts, WHO is in a unique position to tap the best scientific brains in the world for the planning and execution of an extended WHO medical research program. Correspondence received by the Senate Subcommittee on Reorgani- zation and International Organizations from the specialized medical and lay groups mentioned above confirm their high regard for WHO. New horizons of cooperation 'Preceding pages have reflected the many ways in which private organizations have worked effectively with the World Health Organiza- tion. To an American accustomed to the unusually high degree of voluntarism in the United States, it would appear that there are further promising opportunities for WHO to develop still further its relationships with voluntary groups including several not now formally affiliated. Americans must, of course, remember that the character of voluntarism in the United States is relatively unusual elsewhere in the world because of a large variety of factors. All things considered, however, it would appear that WHO can benefit, as can private efforts, throughout the world if there were improved development of health voluntarism nationally and inter— nationally. These additional points might be made in this connection: 1. The responsibility for strengthening voluntarism is naturally on the international organizations affiliated with WHO, as well as with those not now formally affiliated, rather than on WHO itself. Many of the present international organizations are purely of a professional and technical character with comparative minimal or no participation of laymen as contrasted with the pattern in the United States. Of course, many of the nongovernmental groups affiliated with WHO are per se wholly medical in character and must remain entirely professional in composition. But the number of groups which might benefit from lay participation without in any way sacrificing scientific standards is considerable. 2. Many of the organizations have very severe financial prob- lems in meeting even present modest standards of international publications, international meetings, etc. UNITED STATES AND WORLD HEALTH ORGANIZATION 109 Exactly how these organizations may be enabled to strengthen themselves is a problem which merits their own serious attention and that of health-minded individuals throughout the world. 3. Another phase which should be considered is this: WHO would no doubt benefit from closer association with international organizations in the newly developing disciplines, especially those at work at the frontiers of medicine. It is clear that many of the most impressive opportunities for medical development may be found in the new horizons which are opening up in physics, chemistry, and biology. Already the pages of medical history are replete with innumerable examples of great landmark discoveries by professional but nonmedical men. There is every indication that some of the brightest pages of the future of medical progress will similarly reflect the contributions made by indi- viduals not trained as medical doctors, but skilled in related disciplines. How to enable WHO, without altering its basic health char- acter, to get the benefit of the work of organizations in these new fields is a problem which merits review. E. WHO AND U.S. GROUPS The subcommittee is naturally interested in the relationships between WHO and health organizations, public and private in the United States, and also in the extent of cooperation in WHO work by Soviet Russia and the Eastern European countries. This subsection deals with the United States and the next one with the USSR. Upon examination, I found a most extensive network of collabora- tive relations between private and public groups interested in health in the United States and the WHO. 1. Relationships with pharmaceutical organizations 9 The pharmaceutical firms of this country have been active in aiding WhHlO. WHO has in turn been of assistance to the industry as a w o e. For example, WHO has frequently assisted on request by taking part in international collaborative assays of various biological sub- stances preliminary to the establishment of international biological standards for these substances. Some laboratories which have, during the last 3 years, undertaken such research are: Lederle Laboratories, New York, N.Y. Charles Pfizer & Co., Inc., Brooklyn, N .Y. The Upjohn 00., Kalamazoo, Mich. Parke—Davis & CO. Ltd., Detroit, Mich. The Wilson Laboratories, Chicago, Ill. The Armour Laboratories, Kankakee, Ill. Squibb & Sons, New Brunswick, N .J . ‘ Eli Lilly & 00., Indianapolis, Ind. Sharpe & Dohme, Glen Alden, Pa. Baxter Laboratories Inc., Morton Grove, Ill. Through the members of the Expert Advisory Panel on the Inter- national Pharmacopoeia and Pharmaceutical Preparations and other ' See pt. IV, sec. E(3) as regards pharmaceutical preparations and biological standardization. 110 UNITED STATES AND WORLD HEALTH ORGANIZATION specialists, WHO maintains contact with the pharmaceutical firms, and Obtains certain information on tests and methods of assay for a number of im ortant pharmaceutical substances, e.g., from Parke, Davis & Co., etroit. In addition, proofs Of volume II of the first edition of the International Pharmacopoeia, as well as Of the supple- ment, were forwarded to all governments for comments and in the United States were reproduced and distributed by the American Pharmaceutical Association to members of pharmacy and medical college faculties and the drug industry, interested in official standards for drugs. They examined them and sent their comments which were received for integration in the final text Of these volumes. It is intended to follow the same procedure in the preparation of the second edition. Mainly through Dr. J. L. Powers, chairman, Com— mittee on National Formulary, American Pharmaceutical Association, and Dr. Lloyd Miller, director Of revision, U.S. Pharmacopoeia, co- operation has been maintained with the International Pharmacopoeia, most of the work being on the preparation of specifications for drugs and reagents in the International Pharmacopoeia. Cooperation is also Obtained from the editors of the National Formulary of the United States and of\Drug Standards and from the US. Pharmacopoeia. Proposed international nonproprietary names are also examined regularly by the pharmaceutical industry and comments received. At the present time investigations are being made in order to secure further cooperation of the industry to implement the program on information sheets. These sheets would contain information on the quality control of new pharmaceutical substances to be forwarded to national health authorities dealing with the registration and laboratory examination of new pharmaceutical preparations. Also to be mentioned is the impressive cooperation obtained from the Committee of the Pharmacopoeia of the United States. The direc- tor of revision of this pharmacopoeia has been attending the last eight sessions of the Expert Committee on the International Pharmacopoeia. In the venereal-disease field, contact has been maintained with several pharmaceutical manufacturing companies, for example, in the development of long—acting penicillin preparations and other reagents suitable for public health purposes in WHO—assisted VDT projects. The following firms have aided WHO veterinary medicine research: American Cyanamid Co.—Collaboration on zoonoses research. Eli Lilly Co.——Collaboration on rabies research. Abbott Laboratories—Collaboration on hydatidosis research. Finally, the following commercial laboratories have aided in repa- ration of biological products for diagnosis and prevention Of po iomy- elitis and influenza: Lederle, Merck, Sharp & Dohme, Eli Lilly, Parke Davis, Pit- man Moore, Microbiological Associates. Exchange of information on the problem of drugs for leprosy treat— ment has taken place during visitsof research workers or representa— tives of private pharmaceutical companies, such as Lederle Labora- tories, Parke Davis, etc. Exchange of information on therapeutic problems of filariasis has been going on with several research workers or representatives of American pharmaceutical companies such as Lederle (Hetrozan). In summary, the willingness of American industrial concerns to collaborate so extensively with WHO is a tribute toZtheIsoundness of the organization’s programs and of the peoplezengaged‘in‘them. __ UNITED STATES AND WORLD HEALTH ORGANIZATION 111 (A future subcommittee print Will, it might be noted, spell out in detail other international activities of the American pharmaceutical industry.) 2. Relationships with the academic world WHO is in constant touch with deans and other academic leaders on problems of medical education and research. Many of them are on the WHO Expert advisory panels and auxiliary personnel, and from time to time are selected to be members of Expert committees. They are also asked on occasion to act as consultants for WHO to schools of public health and medical schools in many parts of the world. WHO has, in turn, aided medical and related schools through- out the world. Study arrangements for fellows in the United States of America involve consultations, and cooperation with all types of organiza- tions and institutions for service, teaching, and research. This in- cludes cooperation in the modification of existing courses or the establishment of new ones to meet more fully the needs of foreign students (e.g., discussion of WHO stafls with faculties of schools of- public health; consultations with a university concerning the estab- lishment of a course for teachers of preventive medicine, etc.). Co- operation sometimes encompasses joint projects of assistance; e. ., cooperation with the Rockefeller Foundation for the School of Pub ic Health, University of the Philippines. Review of the earlier subsection relating to cooperation of indi- viduals and laboratories will indicate the scope of collaboration with WHO by university teachers and scientists. A brief recapitulation of some of the cooperative relationships with academic research in the field of communicable diseases will serve to reemphasize this point: (1) Investigators at the Universities of Pennsylvania, Tulane, Minnesota, California, and many others have collaborated on veterinary public health research. (2) In a number of endemoepidemic diseases there has been extensive collaboration with many universities and hospitals through members of expert panels: Universities of Harvard, North Carolina, Tulane, Cali- fornia, Texas. . U.S. panel members: Dr. J. A. Doull, Dr. F. A. Johansen, and Dr. H. W. Wade (leprosy). Several professionals from other countries have received WHO fellowships to visit the laboratories of the National Leprosarium, Carville, La. U.S. panel members, interested in onchocerciasis (Parasitic Diseases Panel): Professor E. C. Faust, Dr. H. K. Beye, and Prof. D. L. Augustine. Several experts of American univer- sities and hospitals, schools of public health or health officers are members of the Expert Advisory Panel on Parasitic Dis- eases, and collaborate particularly in the field of filariasis, especially in that of the infections produced by Wucheria parasites. Prof. J. Kessel, School of Medicine, University of California, who is also in charge, as technical adviser of a joint France-American filariasis control project in Tahiti, participated as a WHO expert at the first meeting ,of the, study group on filariasis. . 7 112 UNITED sTATEs AND WORLD HEALTH ORGANIZATION (3) In the field of tuberculosis, Dr. Walsh McDermott, Liv- ingston Farrand professor of public health and preventive medi- cine, Cornell University Medical College, is a member of the WHO Expert Panel on Tuberculosis. He is directing research, including research on tuberculosis in Navaho Indians, in which study problems concerning domiciliary chemotherapy and chemo— prophylaxis on a community basis are being investigated. The exchange of information between Cornell University and WHO at all stages of the studies which they are conducting is proving to be of great importance. (4) In the study Of the biology of the treponematoses, im- munological and other relationships of treponemes, there is a joint research program between WHO and the International Treponematoses Laboratory Center, Johns Hopkins University, Baltimore, USA. The director of this center, Professor T. Turner, dean of faculty and medicine, Johns Hopkins University, is a periodic consultant for WHO. 3. Relationships with foundations and associations WHO and private foundations interested in health have worked closely together since the establishment of the organization. The most extensive collaborative relationships have been with the Rockefeller Foundation because of its long tradition and extensive programs relating to medical research and medical education. (A future committee print in this series will report in detail on the outstanding work of the Rockefeller Foundation.) The participation of the foundation in programs in which WHO is also interested can be best explained by reference to protein malnutrition in part IV. One way to combat protein malnutrition in children is by finding new sources of proteins (besides milk which may be expensive). Considerable research is needed before a food can be accepted as suitable for infant feeding. Several centers throughout the world are carrying out special research. To help this research, the Rockefeller Foundation has recently given $250,000, as previously noted, to further investigations which will assist in the development Of protein- rich foods. This money is being used for grants to various workers throughout the world. These grants are made by a committee of the National Research Council of the United States Of America, with the advice of WHO and FAQ. Various members of this committee are also members of the WHO Protein Advisory Group. Sixteen grants to support the work of 20 research groups in 12 countries had been approved by March 1958. These countries are: Mexico, Guatemala, French West Africa, Nigeria, Belgian Congo, Uganda, Union of South Africa, India, Japan, United States of America, United Kingdom, and France. , It is interesting to note that another leading private foundation in the United States, the Josiah Macy, Jr., Foundation, is also collabo— rating with WHO on nutritional research. Two conferences on protein malnutrition (1953 and 1955) have been sponsored by WHO and FAQ with the assistance of the Josiah Macy, Jr., Foundation. The first one was on the clinical aspects of kwashiorkor. The second one emphasized practical methods of dealing with protein deficiency in the diet of young children. Similar relationships have existed in the field of public health and hospital administration in conjunction with the Kellogg Foundation and others with interests in these activities. UNITED STATES AND WORLD HEALTH ORGANIZATION 113 As is true of the private foundations, the private health associations, particularly those interested in, infectious diseases, collaborate with WHO. Close contact exists, for example, between the National Tuberculosis Association of the United States and WHO concerning tuberculosis problems in all parts of the world. This association is a most active member of the International Union Against Tuberculosis, which is in official relationship with WHO. In the field of leprosy, Dr. James A. Doull and Dr. H. W. Wade, medical director and codirector, respectively, of the Leonard Wood Memorial are members of the WHO Expert Advisory Panel on Leprosy. They have on several occasions acted as WHO Experts at difierent types of meetings or been consulted on various matters. F. RELATIONSHIPS WITH THE U.S.S.R. AND COUNTRIES OF EASTERN EUROPE If improvement of the health of the world is to be truly a worldwide effort, the USSR. and the United States must both participate fully in public health and medical research programs planned and conducted on a truly international basis by WHO. For this reason, I looked ,with special care at the extent not only of US. collaboration, outlined in the preceding subsection, but alsoof collaboration by the USSR. and countries of Eastern Europe. There follows a statement of these relationships as they existed prior to the time I visited Geneva and Moscow. There is every reason to hope that the‘participation of the USSR. in WHO activities, which is already extensive, will broaden substantially in the near future— particularly as concerns medical research. Here is common ground on which all nations may collaborate, irrespective of ideological and other obstacles. Thereby, the cause of world understanding and peace may be significantly served. Eastern states membership The nine states of ‘Eastern Europe (Albania, Czechoslovakia, U.S.S.R., Ukraine, Byelorussia, Poland, Rumania, Bulgaria, Hungary) had all accepted the constitution of WHO without reservation before the first World Health Assembly. Their acceptances were received in the order in which these countries are given in the present para- graph. Some :of these were among the first 26 acceptances which were necessary in order for the constitution to come into force. However, these nine countries informed the Director General, in 1949 and 1950, that they no longer considered themselves members of the Organization. The first notification for this purpose was re- ‘ ceived from U.S.S.R. in February 1949, and the last from Poland in August 1950. p In 1955, during the summer session of EOOSOC, the Soviet delegate, speaking on the social situation in the world, and more especially of the international aspects of public health, declared that WHO was performing a useful work and that, in order to collaborate more efl’ec— tively in international health work, the U.S.S.R. would henceforth participate in the activities of WHO. Three inactive members The ninth World Health Assembly, in 1956, adopted a resolution laying down the conditions for the resumption by inactive members 0 '114 UNITED STATES AND WORLD HEALTH ORGANIZATION of active participation. Of the nine inactive members mentioned above, six have resumed active participation. The three remaining inactive members are Byelorussia, Ukraine, and Hungary. So far as participation in the general direction of WHO is concerned, at the first World Health Assembly, in 1948, the U.S.S.R., Byelorussia, and Poland were elected as members entitled to designate a person to serve on the Executive Board. In 1950, Byelorussia, which had with- . drawn, was replaced by another member state, for the remaining year of mandate. The U.S.S.R. was elected to designate a member of the Board by the 11th World Health Assembly, in 1958. The countries of Eastern Europe have been fairly active in both the operational and the planning phases of WHO activity. Among the actions and proposals relating to operations, the following are illustrative : (1) In 1948 Bulgaria submitted a proposal on physical training to the first World Health Assembly. (2) In 1958 U.S.S.R. made two proposals for the agenda of the 11th assembly—atomic energy and eradication of smallpox. (3) In addition, U.S.S.R. made a contribution of 25 million goses1 of smallpox vaccine, accepted by the 22d session of the car . (4) Moreover, the U.S.S.R. contributed a thousand tons of DDT preparations to WHO, valued at about $82,500 at current prices. With respect to planning activities, a distinguished scientist, whom I had the pleasure of meeting in Moscow, Prof. N. N. Blokhin, director of the Institute of Experimental Pathology and Therapy of Cancer, Academy of Medical Sciences, Moscow, attended the sig- nificant conference in October 1958 on the policies which might under- lie a more extended WHO medical research program. This meeting was also attended by Dr. Josef Charvat, professor of medicine in Charles University, Prague, and member of the Czecho- slovak Academy of Sciences. Soviet experts Since resuming active participation in the affairs of WHO, 58 Russian experts have been appointed by the Director General of WHO to expert advisory panels: Addiction-producing drugs (1) Maternal and child health (3) Antibiotics (2) Mental health (1) Biological standardization (2) Nutrition (1) Brucellosis (2) Occupational health (2) Cancer (1) Organization of medical care (2) Chronic degenerative diseases (2) Parasitic diseases (1) Dental health (2) Plague (3) Environmental sanitation (2) Professional and technical education of Health education of the public (2) medical and auxiliary personnel (2) Health laboratory methods (1) Public health administration (1) Health statistics (1) Rabies (2) Insecticides (2) Radiation (1) International pharmacopoeia and phar- Rehabilitation (2) maceutical preparations (2) Trachoma (1) International quarantine (2) Tuberculosis (1) Leprosy (2) Virus diseases (4) Malaria (2) , Zoonoses (3) UNITED STATES AND WORLD HEALTH ORGANIZATION 115' From elsewhere in eastern Europe, scientists have been appointed to the following anels: Albania: alaria. Bulgaria: Rabies. Czechoslovakia: Health laboratory methods; tuberculosis. Hungary: Malaria; tuberculosis. Poland: Nursing; nutrition; rehabilitation; virus diseases; zoonoses. Rumania: Malaria; rehabilitation. From among these panel members, 24 experts, mostly from the U.S.S.R., have attended a Wide range of expert committee meetings in Geneva and elsewhere: Biological standardization Public health nursing Cardiovascular diseases and hyper- Radiochemical methods of analysis tension Poliomyelitis Auxiliary dental personnel Virus diseases Health laboratory methods Tuberculosis International pharmacopoeia Zoonoses Mental health (problems of the aged) Malaria Plague Medical rehabilitation Preventive aspects of pathology teach- .1118 E Some technical meetings have been held in the countries of eastern urope: Moscow, October 1957, study group on public health labora- tories. Warsaw, November/December 1957, seminar on veterinary public health. Bucharest, June 1958, malaria conference. Since resumption of active membership, the U.S.S.R. has con- tributed financially to WHO activities. In 1958, for instance, the U.S.S.R. paid approximately $1,600,000 out of a total WHO budget of $13,500,000. In comparison, the United States paid $4,500,000 and the United Kingdom $1,150,000. The USSR. is thus the second largest contributor to the WHO regular budget. Further reieirenceL to the Soviet Union and WHO finances may be found in ta 6 6— . Finally, While I was in Europe studying the operation of WHO, the Director General of WHO announced the appointment of a prominent medical scientist from the U.S.S.R., Dr. N icolay Ivanovitch Grash- chenkov, as an Assistant Director ~ General of the Organization. Dr. Grashchenkov will advise the Director General on major policy questions. He Will be responsible for the technical aspects of liaison with regional offices and other agencies. He will deal in particular With the following WHO rograms: Biology and pharmacology; health and vital statistics; e itorial and reference services. G. THE PROPOSED INTERNATIONAL PUBLIC HEALTH AND MEDICAL RESEARCH YEAR The 12th World Health Assembly of the World Health Organization, convening May 12, 1959, will take up the proposal for an International Public Health and Medical Research Year. The background of this proposal provides an interesting sequence in international collaboration. 116 UNITED STATES AND WORLD HEALTH ORGANIZATION The original suggestion for such a ear came from the former Governor of Illinois, the Honorable Ad ai Stevenson, in an address delivered June 8, 1958, at the Michigan State University. On June 9, 1958, the distinguished majority leader of the US. Senate, the Honorable Lyndon B. Johnson Of Texas, printed the text of Governor Stevenson’s address in the Congressional Record. That same day, I publicly commended the address for its farsighted leadership. Immediately thereafter I wrote a letter to the Surgeon General of the US. Public Health Service, Leroy Burney, who was also serving as chairman of the United States delegation to the 11th World Health Assembly, then meeting in Minneapolis. It was my pleasure to serve as a delegate to the same Assembly, holding sessions in the great community which previously I had the privilege of serving as mayor. General Burney had, it should be noted, been elected president of the Assembly as a whole. I wrote to him, however, in his capacity as chairman of the United States delegation. The Surgeon General promptly replied, indicating that because my suggestion for such a year arrived at a time late in the session of the Assembly, as such, there was little alternative but to take it up in- formally with the Executive Board of WHO. On July 1, 1958, I introduced Senate Concurrent Resolution 99. My purpose was to express the sense of the Senate that “the President of the United States be hereby invited to extend to the other nations of the world, through the World Health Organization and related organizations, an invitation for the designation of an International Health and Medical Research Year at such early date as adequate preparations can be made.” On August 11 the Senate Committee on Foreign Relations unan— imously approved the resolution, with minor amendment. Since the time was late in the session and it appeared unlikely that time would be available to clear the concurrent resolution through the House Of Representatives, the Committee on Foreign Relations approved the resolution in two forms—first, as a simple resolution, S. Res. 361, which would require no further House action, and secondly, as a concurrent resolution. Thus, if time proved unavail~ able for the House to take it up, the Senate would have expressed its .Own formal view for this objective in a conclusive way. The sequence Of events turned out as envisioned. The Senate unanimously approved the simple resolution on August 18. A few days later, however, the Congress adjourned; so it did, indeed, prove impossible to complete House action on the resolution in its concurrent orm. Senate Resolution 361 stands, therefore, as the completed expression of the US. Senate. The resolution reads as follows: IS. Res. 361, 85th Cong., 2d sess.] RESOLUTION Whereas the United States has a long and honored tradition, of contributing to international scientific research, including our participation, in 1882-1883. in the First Polar Year; and, in 1932—1933, in the Second Polar Year; and Whereas under the National Science Foundation Act of 1950, approved May 10, 1950 (64 Stat. 149), a National Science Foundation was created “to develop and encourage the pursuit of a national policy for the promotion of basic research UNITED STATES AND WORLD HEALTH ORGANIZATION 117 and education in the sciences”, and ‘ ‘to foster the interchange of scientific informa- tion among scientists in the United States and foreign countries”; and Whereas the Supplemental Appropriation Act, 1955, approved August 26, 1954 (68 Stat. 800), allocated funds for United States participation in the Inter- national Geophysical Year; and Whereas the results of the International Geophysical Year are proving so ini- pressive and constructive that leading scientists and laymen have urged extension of the Year in order that the momentum of discovery and cooperation may be continued; and Whereas no phase of science is of greater significance to mankind than research into the health and well being of man, himself: N ow, therefore, be it Resolved, That the President of the United States is hereby invited to extend to the other nations of the world, through the World Health Organization, and related organizations, an invitation for the designation of representatives to meet and discuss the feasibility of designating an International Health and Medical Research Year, at such early date as adequate preparation can be made, or of other methods of developing such intensive international cooperation in the field of health as will lead toward the discovery and exchange Of the answers on coping with major killing and crippling diseases which affect mankind. Action in United Nations Two and one-half weeks later, on September 6, the Ukrainian Soviet Socialist Republic Offered to the General Assembly Of the United Nations a resolution for the designation of an International Public Health and Medical Research Year. It might be noted at this point that the Ukraine is still an “inactive” member of the World Health Organization (see pt. VI). On December 8, 1958, the United Nations General Assembly approved the resolution, as amended, under the auspices of 22 nations, including the United States. The subject was taken up at the meeting of the Executive Board of the World Health Organization in January 1959, when the Director General of WHO was asked to prepare for the 12th Assembly plans for the proposed year. The resolution of the Executive Board reads as follows: REsOLUTION OF THE EXECUTIVE BOARD (EB23, R72, February 2, 1959) INTERNATIONAL HEALTH AND MEDICAL RESEARCH YEAR ‘ The Executive Board, Having studied resolution 1283 (XIII) of the General Assembly of the United Nations on an International Health and Medical Research Year, whereby the General Assembly “Invites the World Health Organization to consider, in accord- ance with article IV of the agreement between the United Nations and the World Health Organization, the recommendation to organize, primarily on a national basis, an International Health and Medical Research Year, preferably in 1961, and to adopt methods for intensifying international cooperation in this field. * * *” Having studied an associated proposal for the consideration of designating an International Health and Medical Research Year or of adopting other means for intensifying health cooperation against major killing and cripplin diseases; Having studied the working paper presented by the Director- eneral 1° on an International Health and Medical Research Year; 1. EXPREsSEs its appreciation and satisfaction at learning of the interest dis- played in international health matters, including medical research; , 2. BELIEVES that the observing by all countries of an International Health and Medical Research Year would result in an intensification of efforts in health and medical research work, and would thereby further the objectives of the World Health Organization as established by its constitution; 3. BELIEVES that should the Twelfth World Health Assembly decide to arrange for an International Health and Medical Research Year, the year should be observed by simultaneous and coordinated action on a national and international 1' Documentfl: Baa/w P15. 118 UNITED STATES AND WORLD HEALTH ORGANIZATION basis, with emphasis on national undertakings to be suggested and coordinated on a regional and world-wide basis; 4. REQUESTS the Director General to circulate to Member States and Associate Members the proposal to observe an International Health and Medical Research Year, together with the documentation which was before the Board, to assist them in reaching a decision at the Twelfth World Health Assembly; 5. REQUESTS the Director General to continue to study this matter and to sub- mit a comprehensive report on all aspects of the subject to the Twelfth World Health Assembly based on the documentation which was before the Board as well as discussions in the Board, and to include specific plans for the celebration of the International Health and Medical Research Year. Factors in evaluating IH Y From the very inception of the proposal, it was recognized that the International Health Year is dissimilar in many respects to its most notable predecessor—the International Geophysical Year. IGY Offered the possibility of simultaneous observations in many parts Of the world of the very same precise cosmic and other phenomena. The factor of simultaneity was a crucial element in the scientific re- porting. This and other features are dissimilar to the International ublic Health and Medical Research Year. Nevertheless, it is clear that IHY, as it might be termed, Ofi’ers im- pressive Opportunities to the world. It would launch programs on a basis Of broader coordination than ever before. It would identify major targets for concerted and in- tensified action not simply over a 12-month, or even an 18—month period, but over much longer duration. -' It would elevate the thinking Of governments and peoples to the unmet needs and challenges Of public health and medical research. WNaturally, vagueness or diffusion of purpose would have to be avoided. Only goals which would be actually attainable in terms of specific vulnerable diseases would have to be set. SO, too, the lay public would have to be cautioned that medical research promises no cures or advances by timetable or calendar. Medical research re- quires patience, flexibility, and an ever broader base of skilled man— power. Careful, systematic phasing in Of programs is especially essential in strengthening public health. Well prepared and well implemented, IHY could flflflme the tangible and intangible assets Of world health to higher levels than ever before attained. Sustaining those levels after IHY’s conclusion would naturally be indispensable. H. THE HIGHEST ASSET—MORAL PURPOSE This report has addressed itself to a variety Of considerations which impel the United States to continue to give generously Of its” resources toward the World Health Organization. The most significant consideration, however, derives from the most basic impulse 1n the heart of the American people—a moral impulse. The foundation of the United States is a moral foundation. It cannot be tOO often stated that the strength of the United States is not basically material, but rather the strength Of its ideals, its princi- ples. We are strong to the effect that we fulfill the noble philosophy upon which we were founded, sustained, and upon which we have grown to greatness. But we are hardly alone. UNITED STATES AND WORLD HEALTH ORGANIZATION 119 The moral view is fundamental to all those anywhere in the world to whom the oath of Hippocrates is dear. It is a view shared by all men of good will of every nationality and faith throughout the world. WHO is, therefore, a tool for the fulfillment of a credo of humanity which knows no frontiers. WHO is an asset to all those interested in fulfillng that credo. And it can count in turn as an asset in its own worlii the very existence Within hearts everywhere of an impulse for goo . Most pertinent to our consideration of this factor are observations made by the U.S. member of the Executive Board of the WHO organization, Dr. Henry Van Zile Hyde. On the occasion of delivering the WiIdSIOW lecture at Yale University March 28, 1955, Dr. Hyde observe : * * * the growing recognition of the world as an essential whole provides the milieu within which health action spreads rapidly and widely without too great reference to artificial boundaries. Interrelatedness has replaced isolation, and there is a true sense of mutual responsibility for the state of the world at large. In the free world, this sense of mutual responsibility is not motivated by political or economic opportunism alone. Much deeper and more meaningful forces under- lie today’s internationalism. The moral concepts that have shaped our own American freedom are known throughout the world and are inspiring today‘s movements toward freedom. The Declaration of Independence is not solely a U.S. doeument but a world platform; Lincoln is not a local figure but a world hero and a universal symbol of faith and hope. We can easily recall how the Atlantic Charter and its four freedoms electrified us only a few years ago. We wish to make good on those promises. We cannot indeed sidestep moral responsibility for preventing disease because we know, with Thucydides, that “the true author of the subjugation of a people is not so much the immediate agent, as the power which permits it, having the means to prevent it.” And we are the ones who have the means to prevent disease. The moral drive underlying international action does not stem solely from' political philosophies or from guilt but from a deeper root that underlies phi- losophy and guilt. It is perhaps a fortunate thing that the power and the wealth O and a large measure of the greatly needed technical skills are in the hands of those . whose religion drives them toshare their substance. The medical missionary is a. forerunner in spirit, more than in technique, of the oflicial international programs in health. Where can we derive more immediate satisfaction of our moral urge than in the field of health, sharing our resources in order to solve the massive immediate human problem touching every man? Freeing man from the burden of disease so that he might have flight of spirit satisfies the requirements of today’s moral urge as well as any immediate material goal. Whether programs are labeled health, agriculture, economic development, or technical assistance, the improve- ment of man’s daily life is their goal, and, directly or indirectly, they must bear upon man's health. All of this is of particular importance to us as workers in public health. We cannot think of peace as a problem solely for the diplomat or the statesman, nor of economic development as a problem for the economist alone. The emergence ,of man toward health constitutes a fact of our times within our own sphere of responsibility that is very truly affecting the future of mankind. India will never again be what it was yesterday, nor will Brazil, nor Mexico, nor Haiti, nor Indonesia, nor any country in the so-called underdeveloped belt. We, as professionals in the field of health, have the primary responsibility for assuring that this great force, which is expressing itself with explosive rapidity, is utilized to the fullest extent in the furtherance of freedom and the establishment of peace. It is encumbent upon us not only to recognize it but to understand it much more deeply than we do today. As in the case of any great force, it can be used well or badly for good or for evil. Its proper use is our particular and in- escapable world responsibility. May we discharge it wisely and for the better- ment of all mankind; \/ 120 UNITED STATES AND WORLD HEALTH ORGANIZATION Prime Minister Nehru’s comments Certainly, mankind is united in principle on behalf of one supreme goal—peace. Toward that goal, common good works, such as works for improved health, serve significantly to ease misunderstandings and tensions. We might recall now a pertinent summary from a press release, datelined New Delhi, India, September 21, 1954, quoting Prime Minister Nehru: The significant contribution being made by nonpolitical U.N. agencies such as the World Health Organization toward easing world tension and resolving conflict outside their own immediate fields of action was highlighted by India’s Prime Minister Jawaharlal Nehru this morning in an address inaugurating the Seventh Session of the WHO Regional Committee for Southeast Asia at Patiala House, New Delhi. * * * The Prime Minister dwelt at length on what he called the “indirect approach” to the settlement of controversial issues in human affairs. Pointing out that statesmen and politicians were engaged in efforts to solve world problems directly, he declared that the “indirect approach’ ’ through the type of work being done by WHO. UNESCO, and other U.N. specialized agencies might actually achieve the desired objective sooner. The indirect approach, he said, was able to get around the defenses of the opposition, while the direct approach often led to direct aggressive defense. Comments by Egypt’s Minister of Health Similarly notable is an excerpt from a speech of Dr. Nur—El-Din Tarraf, Minister of Health, Government of Egypt, at the Inaugural Session, WHO Regional Office for the Eastern Mediterranean, Re- gional Committee for the Eastern Mediterranean, Seventh Session, Subcommittee A, September 23, 1957. I seize this opportunity to express to the states of this region and other countries; as well as to national and international organizations, Egypt’s great appreciation of the medical and health assistance they offered her in her unexpected crisis. Such assistance doubles our confidence in the value of international cooperation in all fields of health. It fortifies our faith in the World Health Organization as the most efficient body which, by the nature of the work it does and the function it performs, can tighten the bonds of cooperation and understanding among the nations of the world, and consolidate the foundations of peace and unity amongst them all. A unity in humane action, a sharing of common devotion to man’s good—this is the essence of the healing arts. Views of Dr. Raymond Fosdick Turning backward still further, 2 years before the International Health Conference, Dr. Raymond B. Fosdick, then president of the Rockefeller Foundation, stated, with customary vision: The community of nations has got to have a kind of intellectual and Spiritual integration before it can be absolutely sure that the forces of Violence are under control. Consequently there must be developed for international life new areas ‘ and techniques of cooperative action * * *. We need rallying points of unity, centers around which men of differing cultures and faiths can combine, defined fields of need or goals of effort in which by pooling its brains and resources the human race can add to its own well-being. * * * Dr. Fosdick saw hope only—— as we begin to build, brick by brick, in these areas of common interest where cooperation is possible and the results are of benefit to all. * * * Part VI WHO’S MATERIAL RESOURCES While collaborative effort is a remarkable aspect of the operation of the World Health Organization, the programs must also be supported by money and manpower. _ ' In this section, the rowth, distribution, and current status of WHO’s budgets and sta ng are briefly outlined. As modest as the present level of WHO’s financial resources will be shown to be, fortunately they compare favorably with the feeble resources previously available to international health. For example, the health budget of the League of Nations never exceeded $400,000, of which only $200,000 was contributed by governments. During the interwar period, it is estimated that the total annual contribution to international health work never reached $300,000, including contribu- tions to the International Oflice of Public Health in Paris and the Pan American Sanitary Bureau. Of that sum, the United States, which was not a member of the League, contributed only $6,000 to the world program and $60,000 to the hemispheric one each year. A. wno’s TOTAL RESOURCES 1. Total finances WHO currently finances its operations (1959 budget) from three sources, divided roughly as follows (for precise details, see tables 6—A, 6—B, and charts 6*A and 6~B). Amount Source (rounded Perwnt to nearest million) Total resources. $26 100 Regular budget .......... 15 60 Malaria eradication special account .......................................... 6 2) Expanded program of technical assistance ................................... 5 20 The total funds available to WHO have grown to the current level of $26 million from about $13 million in 1953. However, the resources have less than doubled in real terms because of the worldwide infla‘ tionary trend over these years. In connection with collaboration among international agencies, it is worth noting that UNICEF and WHO jointly support many projects. WHO provides health personnel for these projects, subject to avail- ability of funds. In earlier years, UNICEF reimbursed WHO for some international health staff for which WHO did not have funds. This reimbursement amounted to approximately $500,000 per year from 1952 through 1955. Thereafter, however, the reimbursements declined, and in 1958 and 1959 no reimbursement is regarded as necessary. 121 38516—59—9 122 UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE 6—A.——-Distribut'ian of contributions to the 1959 regular budget of WHO Amount Cumulative Major contributors to the regular budget of WHO (nearest Percent percent thousand) Total-..,. ............................................... $14, 966 100. 0 100. 0 Total by largest contributors ........................... 11, 456 75. 5 .............. United States ................................................. 4, 744 31. 7 31. 7 U.S.S R---..---_ 1,916 12.8 44.5 United Kingdom ................................. 1, 072 7. 2 51. 7 France...-.-.---- 783 5. 2 56. 9 China .......................... 705 4. 7 61. 6 Germany (Federal Republic)... 584 3. 9 65. 5 Gene .... 435 2. D 68. 4 India. - 408 2. 7 71. 1 Italy -. 287 1. 9 73.0 .19. an ........... 269 1. 8 74. 8 311113“ a s R _ 253 1. 7 76. 5 Other 77 contributors 3. 510 23. 5 100. 0 TABLE 6—B.— Obligations incurred 1.959 to 1.957 and estimated costs for 1.958 and 1959 under the regular budget, the malaria eradication-special account, the expanded program of technical assistance, and UNICEF reimbursements 1952 1953 1954 1955 Dollars Percent Dollars Percent Dollars Percent Dollars Percent Regular budget of WHO 7, 938, 850 62. 35 8, 112, 605 63. 39 8, 134, 514 65, 46 9, 275, 300 65. 60 Malaria eradication special account. ....... Expanded program of technical assistance ______________________________ 4, 351, 689 34. 18 4, 189, 357 32. 73 3, 754, 545 30. 22 4, 411, 749 31. 21 Costs reimbursed by UNICEF for jointly assisted UN ICEF/WHO projects 441, 835 3. 47 496, 645 3. 88 537, 351 4. 32 451, 538 3. 19 Total- 12, 732, 374 100.00 12, 798, 607‘ 100.00 12, 426, 410 100. 00 14, 138, 587 100.00 1956 1957 1958 1959 Dollars Percent Dollars Perwnt Dollars Percent Dollars Percent Regular budget of WHO 9, 982, 794 64. 21 12, 091, 421 68.33 13, 433, 922 58. 32 { 14,1232: 333 5;- $3 Malaria eradication special account. _____ 28, 247 0. 16 3, 830, 356 16. 63 5, 920, 874 22. 61 Expanded rogram of technical assistance .............................. 5, 452, 504 35.07 5, 527, 977 31. 24 5, 770, 643 25. 05 5, 130, 403 19. 79 Costs reim ursed by UNICEF for jointly assisted UNICEF/WHO protects ___ _ 112, 058 0. 72 47, 972 0. 27 ..... Total 15, 547, 356 100. 00 17, 695, 617 100. 00 23, 034, 921 100. 00 26, 184, 463 100. 00 1 Amount expected to be reimbursed from the ex anded program of technical assistance expanded program of technical assistance funds. toward the costs of administrative and operatio services previously paid directly from MOILVZINVDHO HrL’IV’ElH (I’IHGAA (INV SELLVCLS (I'JLLINfl EZI 124 UNITED STATES AND WORLD HEALTH ORGANIZATION Cm'r 6-A AMOUNTS AUTHORIZED FOR USE BY WHO 1 953-1 959 USS mflhon / /////// /////////// /////////// /////////// /////////// llll, ,;;;;; /////////////// /////////////// /////////////// /////////////// / // / //v// / . //////////////// //////////////// /////////////// /////////////// // I /ll ////////////// ////////////// ////////////// ////////////// ////////////// ..L// / ///// .;//////////// //////////// //////////// n/////////// ///// .7///////// x///////// ////////// ////////// u////////// .. III/l) H/////////// H,/////////// n,/////////// 4/////////// x /// // / / _ _ _ _ _ _ _ _ _ _ 6 4 2 0 8 6 4 2 o 2 2 2 2 1|- ] 1| 1| 1 1953 1954 1955 1956 1957 1958 1959 Imam» \\\\\\\\\ 3:12:11 529.3332. Technical Auiflunco funds m Rcaulor fund. 7 Expand“ Programmo of n C h m P 0 H w / F E m N U 5 u s .u I a .w. I .m .ol r to. lo. n n G t I O P .m k n h c I T (Included undo! Other Extra-budg'flury Funds) for which UNICEF has allocated fundl. UNITED STATES AND WORLD HEALTH ORGANIZATION 125 CHART 6—B REVISED ESTIMATES UNDER REGULAR BUDGET FOR 1957 COMPARED WITH APPROVED 1958 AND 1959 ESTIMATES s “287600 3 mafia 3 12190715 $ 7159845 Fluid Activiviu S 6557 776 3 58"”5 ' Roinburnmom of Waking Capital Fund R-gionul Officu Expon Common Advisory Smicu (Hndquurnn) Control T-chnicul Sonic" Adminishatin Sonic" Org. Warnings lno 1‘90 2. Regular budget With respect to the regular budget, the expenses of WHO are, under article 56 of its constitution, apportioned amon the members in accordance with a scale fixed by the Health Assem 1y. The scale is, by decision of the World Health Assembly, based on the scale of assessments of the United Nations, taking into account the difference in membership. Eighty-eight countries contribute to the regular budget of WHO. The amounts of the contributions vary widely because of Wide varia- tions in economic capacity. One of the most remarkable aspects of the regular budget is the Willingness of countries with meager re- sources to help With the common effort. 126 UNITED STATES AND WORLD HEALTH ORGANIZATION When the size of national contributions 15 examined, it becomes clear that contributions are quite highly concentrated. Somewhat . more than half of the funds are provided by the United States, the Union of Soviet Socialist Republics, and the United Kingdom. Three- quarters of the contributions to the regular budget of WHO are made by the 11 countries which contribute more than $250, 000 per year (tables 6—A and 6—0). TABLE 6—C.—Contributions to the 1959 regular budget of WHO, by country Scale of Scale of assess— Corre- assess- Corre- Members and associate merits sponding Members and associate merits sponding members for i959 contri- mem ers for 1959 contri- butions butions Units Units Afghanistan ______ 8 (1) $5, 990 Albania-- (1) 8, 160 Argentina 137 (1) 5, 990 Australia 195 (1) 5, 990 Austria.-- 42 8 9, 320 Belgium” 150 26 30, 300 Bolivia..- 7 82 95, 570 128 (I) 5, 990 17 4 16, 320 12 p (1) 5, 990 56 65, 260 Netherlands _____ - 135 157, 340 (1) 5, 990 New Zealand_... - 51 59, 440 373 434, 730 Nicaragua _______ - (1) 5, 990 13 15, 150 Nigeria __________ 3 3, 500 35 40, 790 N 58 67, 600 605 705, 110 Pakistan. . 65 75, 760 (1) 5, 7 8,160 31 36,130 (1) 5, 99 115, 380 Peru ............ 18 20, 980 77 89, 740 48 55, 940 7 8, 160 Polan ..-- 183 213, 290 7 8, 160 Portugal... 29 33, 8 9, 320 Rumania.-._ 59 68, 760 13 15,150 Saudi Arabia 8 9, 320 Sierra Leone 3, 3 3, 500 Spain. 133 155, 010 43 50,120 Sudan. 13 15,150 France. 672 783, 210 Sweden. .-.. - 173 201, 630 Switzerland ....... - 119 138, 690 501 Thailand .......... . 20 23, 310 8 . 8,160 24 . 73 85, 080 8 . 217 252, 910 (1) ........ 81 94. (l) ' 5, 990 Union of Soviet Socialist Re- 47 54, 780 pasubli ..................... 1, 644 1, 916, 060 (I) 5, 990 United Arab Republic. . 51 59, 440 350 407, 920 United Kingdom ........ - 920 1,072, 250 60 69, 930 United States of America (3) , 744, 31 36, 130 Uruguay .............. . 23, 310 14 16, 320 Venezuela. - 51 59, 440 22 25, 640 Vietnam..- . 23, 310 20 23, 310 Yemen- . -. . (l) 5, 246 286, 710 Yugoslavia . 42 48, 950 231 269, 230 orand (1) 5, 990 Total ................... 8, 688 14, 965, 660 Korea, Republic of ........... (1) 5, 990 1 Minimum assessment of 0.04 percent. 9 Special assessment 011 largest contributor representing 32. 51 percent of active members’ assessments. UNITED STATES AND WORLD HEALTH ORGANIZATION 127 The budget of WHO does not include the budget of the Pan American Health Organization (formerly the Pan American Sanitary Organization). In 1958 the budget of the Pan American Health Organization was $3 million. In addition, it administered a special malaria fund amounting to $3.3 million (see table 6—D). The WHO did, however, include about $2.7 million for its re ion of the Americas. The PAHO serves as the regional organization 0 WHO. TABLE 6~D.—Approved budgets of the Pan American Health Organization and the special malaria fund, and funds obligated in the region of the Americas from WHO for the years 1952—67, with estimated costs, 1958 and 1.959 Pan American Health World Health Organization Organization Year , Special Expanded Reimbursed Approved malaria Regular program of y Total budgets fund budget technical UNICEF assistance $1, 973, 681 $909, 310 $905, 912 $19, 656 $1, 834, 878 2, 060, 000 . 1,001,137 880, 437 7, 958 l, 889, 532 2,100,000 930,1 9,003 23 409 1,642,593 2, 100, 000 . 1, 043, 631 957, 878 30, 605 2, 032, 114 2, 200, 000 1, 152, 606 1, 092, 906 4, 7 2, 250, 245 2, 400, 000 $922, 345 1, 308, 419 1, 160, 308 .............. 2, 468, 727 3, 000, 000 1, 785, 960 1, 533, 692 1,153,166 ______________ 2, 686, 858 3, 600, 000 3, 283, 660 1, 668, 618 1, 102, 848 .............. 2, 771, 466 3. Malaria eradication special account The malaria eradication special account, established by the Eighth World Health Assembly is credited with voluntary contributions from governments or other sources. Funds in the malaria eradication special account may be used only for malaria eradication work. In 1959, this account will approximate $6 million. This invest- ment, even after taking account of the additional resources provided by national governments under their own malaria eradication pro- grams, is undoubtedly one of mankind’s finest bargains. For a rela- tively small sum an age-old scourge of mankind has, as pointed out in part III, been obliterated as a major health hazard over large portions of the globe. With sustained and intensified effort, backed by ade- quate research, further strides will be possible. Ultimately, the citadel of malaria—Africa—may be successfully stormed. 4. Expanded programs of technical assistance WHO is responsible for the health aspects of general economic pro- grams undertaken under the United Nations Expanded Program of Technical Assistance for Economic Development of Under—Developed Countries. Funds for the program, amounting to more than a fifth of WHO’S total annual resources are derived from voluntary pledges which governments make to the special account established for that purpose. 128 UNITED STATES AND WORLD HEALTH ORGANIZATION B. GENERAL EXPENDITURE PATTERNS Both the current general pattern of expenditures and trends over the past years can be seen by looking at a simple percentage distribution (see table 6—E and chart 6—C). - Broad activity 1952 l 1958 1 Percent ‘ change Total 100 100 .............. Field operating programs _____________________________________ 67 74 +7 Headquarters operating programs.. 20 17 —3 Organizational meetings ________________________ 2 2 .............. Administrative services 1 ...................................... 11 7 -4 l Percentages rounded off to permit easy comparison. 1 Administrative expenses, as defined by the executive board uniformly for the period in question, cover all activities which facilitate and provide services for carrying out the objective of the Organization. They include all expenses arising from coordinating, administratively planning, organizing, staffing, and financing the programs. They include the Director General and his staff, public information, budgeting, accounting, general servicing, management, personnel administration, and other similar services. TABLE 6—E.—Breakdown of obligations by major purposes, 1952—57, and estimated costs for 1.958 and 1959 under the regular budget, malaria eradication special account, expanded program of technical assistance, and UNICEF reimbursements 1952 1953 1954 1955 Amount Per. Amount Per- Amount Per- Amount Per- cent cent cent cent Organizational meetings .......... $275, 998 2. 2 $272, 096 2. 1 $272, 802 2. 2 $349, 123 2. 5 Administrative - services ............ 1, 364, 270 10. 7 1,312, 017 10. 3 1, 225, 882 9. 9 l, 290, 118 9. 1 Operating program: Headquarters ...... 2, 465, 326 19. 4 2, 530, 298 19. 8 2, 689, 314 21. 6 2, 971, 511 21.0 Field ______________ 8, 497, 450 66. 7 8, 684, 196 67. 8 8, 238, 412 66. 3 9, 527, 835 67. 4 Total ____________ 12, 732, 374 I 100. 0 12, 798, 607 100. 0 12, 426, 410 100. 0 14, 138, 587 100. 0 1956 1957 1958 1959 Amount Per- Amount Per— Amount Per- Amount Per- cent cent cent cent Organizational meetings .......... 3351, 935 2. 3 $373, 361 2. 1 $429, 040 1. 9 $439, 350 l. 7 Administrative . services ............ 1, 242, 839 8. 0 1, 383, 256 7. 8 1, 513, 820 6. 6 1, 564, 142 6. 0 Ofirating program: eadquarte .- _ 2, 991, 507 19. 2 3, 298, 075 18. 7 3, 872, 230 16. 8 4, 044, 097 15. 4 Field .............. 10, 961, 075 70. 5 12, 640, 925 71. 4 17, 119, 831 74. 3 20, 036, 874 76. 5 Total ____________ 15, 547, 356 100.0 17, 695, 617 100. 0 23,034, 921 3 100. 0 26, 184, 463 1 100. 0 1 Includes $129,330 building fund (headquarters), 1 percent of total. ' Includes $100,000 (0.4 percent of total). Appropriated to repay working capital fund for amounts with- drawn in connection with erection of regional oflice building at Manila for western Pacific region. UNITED STATES AND WORLD HEALTH ORGANIZATION 129 CHART 6—0 APPROVED us: or 1953 BUDGET, av "newness Central Technical Sorvleu Regional Ofllcu 13.30 9‘ 13.18 X Expo" Common 1.“ % Organlulloncl Mumm- 3.00 K Rolmbwnmm of ----------- Waking Capl'al Fund 0.74 5‘ Advllory Sorvlcu 59.00 ’5 "0 W” 1. Rising operating programs About nine—tenths of all WHO expenditures are for operating pro- grams. Currently about three-quarters of the total WHO budget supports field operating programs. Since 1952 there has been a sub- stantial increase in the proportion of funds devoted to field operating programs and a decline in the proportion of funds spent for head- quarters operating programs. Organizational meetings continue to consume about 2 percent of the WHO budget, but the figure in 1952 was somewhat above and the current figure somewhat under 2 percent. 2. Declining share absorbed by administration Administrative costs have decreased from 10.7 percent of total costs in 1952 to 7.8 percent in 1957 and are planned to decrease to 6 percent in 1959, with an absolute increase of $200,000 from 1952 to 1959, a period during which program operations increased by some $14.2 million, or more than 220 percent. C. FINANCIAL AUDIT The question of accountability for funds arises in connection with an organization which handles millions of dollars a year and spends money in most of the countries of the world. To deal With this problem, the accounts of the Organization are audited annually by an external auditor. This is done in great detail and with the utmost meticulousness. For example, the Financial Report and the Report 130 UNITED STATES AND WORLD HEALTH ORGANIZATION of the External Auditor to the World Health Assembly, January 1— December 31, 1957 (N o. 85 of the Official Documents of the World Health Organization), is a 67-page document. The external auditor summarized his findings as follows: GENEVA, March 21, 1.958. I have reviewed the Organization’s overall system of financial control, par— ticularly its application to the accounting and financial operations of these two regional offices. As a result of this examination I am of the opinion that the system functions well. I have also examined the reports of the internal auditors :ndfhave been able to follow up their work, which has given me complete satis- ac ion. Finally, I would state that the financial situation of the organization is sound. This year when the World Health Organization celebrates its 10th anniversary it may be appropriate for me to make a brief general comment regarding the management of the funds of the Organization. The Ad Hoc Committee appointed to act on behalf of the Executive Board to deal with my reports on the audits of the Organization’s accounts included during earlier years in its remarks comments on the value of the auditor’s reports. At that time I was obliged to draw attention to defects that existed—to speak frankly of an unsound financial position, or of the inadequacy of the Working Capital Fund, and the like. As time passed and these defects were Overcome, and as the Secretariat gained in experience, these critical remarks disappeared from my reports. And now, the control exercised over all transactions has attained such a standard that I feel obliged to felicitate/the World Health Organization on the occasion of its 10th anniversary on its very good and sound financial administration. The audit was facilitated in every way by the Officers of the Organization. Every opportunity was offered for examination of the records, vouchers and documentation, for all of which I wish to express my appreciation. (Signed) UNO BRUNSKOG, External Auditor. The United States can have full confidence that the funds which it supplies to WHO are accounted for to the penny. D. THE SUBSTANCE OF FIELDWORK The nature of the program that absorbs a large share of WHO funds—fieldwork involving direct assistance to governments pro- vided at their request—can be shown in historical perspective. While such distributions must be interpreted with care in making detailed comparisons,11 some general observations are valid (table 6—F). First, there have been no rapid or marked changes in program emphasis. Gradual evolution has been characteristic of program changes. Second, every program but one has grown in absolute size. Third, the largest declines have been in disease areas Where scientific advances have made it possible to produce a striking degree of disease cOntrOl with relatively moderate expenditures. Tuberculosis and venereal disease programs fall in this category. Fourth, about a quarter of all WHO projects fell in both 1952 and 1957 in the field of public health administration and another category of miscellaneous projects. 11 For example, a decline is shown for maternal and child health program and an increase for nursing. However, some nursing expenses that were budgeted as maternal and child health expenses in 1952 had been transferred to nursing by 1957. As another example, some field programs are jointly financed with other agencies and some are not, and the cooperative arrangements change over the years. UNITED STATES AND WORLD HEALTH ORGANIZATION 131 Fifth, the largest program increase has been in malaria as a con- sequence of the malaria eradication program. This program is so significant as an experiment in international collaboration, as a suc- cessful disease control program, and as a precedent for other programs that it needs further explanation. TABLE 6—F.—0bligations in respect of projects by specific fields of activity, 1952—57, under the regular budget, expanded program of technical assistance, and UNICEF reimbursements Activity 1952 1952 1953 1954 1955 1956 1957 1957 Per- Per- cent cmt 10.05 $675,639 $620, 295 $463,117 $707,121$1,013,019‘$1,206,223 13.50 16. 79 1,061,375 1, 048, 314 987, 117 868, 308 922, 132 724, 704 8. 11 Tuberculosis. . . Venereal diseases nematoses ................. 7.41 498,090 460,035 391,027 338,672 310,106 344,274 3.85 Endemo-epidemic diseases... 5.56 373,579 456,986 475,974 521,875 501,761 684,869 7.67 Public-health administra- tion ....................... 24. 30 1, 633, 283 1,659,861 1, 110, 357 1, 461, 676 1, 647, 716 2,197, 359 24. 59 Nursing ..................... 6. 93 465, 652 631, 552 548, 369 821, 942 807, 998 842, 559 9. 43 Social and occupational health _____________________ 1. 82 122, 450 79, 983 47, 671 72, 286 31, 561 87, 369 . 98 Health education of the ublic _____________________ l. 40 94, 111 146, 523 113, 790 124, 991 137, 759 244, 037 2. 73 eternal and child health... 9. 28 623, 639 745, 498 687, 044 623, 423 758, 630 615, 469 6. 89 Mental health _______________ 2. 09 140, 480 207, 169 121, 982 175, 146 97, 364 158,041 1. 77 Nutrition ....... 78, 943 25, 281 47, 469 107, 723 115, 495 126, 300 l. 41 Environmental s 150, 217 358, 446 337, 514 404, 987 477, 440 634, 270 7. 10 Other projects.- 803, 256 280, 007 594, 270 ' 641, 790 812, 055 1, 069, 300 11. 97 Total .................. 100. 00 6, 720, 714 6, 719, 950 5, 925, 701 6, 869, 940 7, 633, 036 8, 934, 774 100. 00 1 Includes $28,247 obligated from the malaria eradication special account. E. WHO’S MALARIA EBADICATION PROGRAM The objectives, operational methods, and attainments of the WHO malaria eradication program were described in part III. Here empha- sis will be placed on the financial aspects Of the program. WHO’S total expenditures relating to malaria were $6.5 million in 1958 (table 6—G). Of this sum, $3.8 million came from the malaria eradication special account. These are substantial expenditures, but they are an investment with a fantastic yield in both human and economic terms. The WHO expenditures are made primarily tO aid national govern- ments to fill gaps not met by national programs, to provide technical aid and training, and to stimulate national governments. In 1958, governmental expenditures for malaria eradication totaled $50 million or almost eight times the total WHO expenditure. WHO malaria expenditures also finance work involving two or more countries or regions. In 1958, about $1.5 million—or about 25 per- cent—of WHO’S estimated malaria expenditures supported such work. The United States initially financed the malaria eradication special account in the amount of $5 million in 1957 (table 6—H). A further contribution of $3 million was made in early 1959. A number of countries with relatively limited resources also contribute to the fund. Neither the UK. nor the U.S.S.R. contributes to the finances. The U.S.S.R. has, however, contributed $82,500 worth of DDT in kind. 132 UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE 6—G.—Estimated government contribution to malaria eradication programs in their countries for the years 1958, 1.959, and 1.960, with estimated costs to WHO (all funds) 1958 1959 1960 Country Govern- WHO Govem- WHO Govem- WHO ment ment ment Afghanistan .................. $81, 327 $49, 660 $91, 250‘ $56, 202 $100, on $64, 726 Angola, Cape Verde, and Mozambique. ............. (1) 15, 320 (1) 40, 828 570, 000 135, 129 Argentina ........ . 378, 378 11, 453 378, 378 34, 133 378, 378 2, 088 Bechuanaland ................ (l) (1) (1) ) (l) 100, 460 Belgian Congo and Ruanda Unmdi ..................... (l) (1) (1) (1) (1) Bohvia. _ _ 450. 000 60 759 450, 000 83, 359 450, 000 88, 626 Brazil _______ 3, 000, 000 110, 430 3, 000, 000 214, 904 3, 000, 000 198, 320 British East Africa ___________ , 458 , 780 76, 458 27, 500 76, 4 (I) British Guiana and West Indies ______________________ 25. 000 1, 580 25,000 11, 948 25, 000 9,875 British Honduras ............. 20,048 4, 380 .048 , 490 , 048 8, 640 British Solomon Islands Pro- ' tectorate .................... (1) (1) x) (1) (l) 5, 000 1 I 1) 8,690 (I) 3, 320 937, 697 57, 810 860, 572 60, 784 El) 60, 934 230, 000 55, 935 230, 000 64, 739 1) 68, 815 44 847 68,330 119, 959 70, 294 107, 776 72, 100 2, 741, 935 117, 273 2, 741, 935 179, 464 2, 741, 935 182, 372 0, 530 , 10, 530 32, 65 10, 530 30, 944 100, 000 14 321 100, 000 18, 333 100, 000 16, 116 Dominican Republic 450, 000 74, 416 450, 000 96,405 50, 000 98, 26 Ecua or ......... 450,450 61, 594 450, 450 81,206 450,450 88,366 El Salvador" 497, 600 67, 374 497, 600 77, 112 240, 000 86,764 Ethiopia ______________________ 46, 800 55 150 , 000 91, 526 (I) 67,914 Federation of Rhodesia and Nyasaland .................. 79, 450 31, 400 140, 000 73, 376 140, 000 187, 370 France (Algeria). 1 (1) (1) 43, 927 1) 26, 531 French Africa. ........ . . . 338, 014 34, 020 365,074 99, 403 365, 074 203, French Antilles and Gulana._ 100, 000 7, 371 100, 2,096 ,000 2, 096 French West Africa ...... - . . 392, 850 7, 700 392, 850 19, 671 392, 850 16, 568 53, 505 27, 189 63, 436 165, 083 (l) 130, 000 70, 089 480, 000 73, 892 199, 077 400, 000 210, 724 58, 83 375, 000 , 785 229, 992 22, 533, 809 204, 206 472, 347 3, 996, 037 528, 315 107, 630 (l) 99, 067 71, 403 1,400, 000 67, 074 7, 400 (l) O) (1) (1) (9 19, 101 (l) 17, 466 45,467 (I) 16, 150 (1) 12, 907 67, 452 116, 288 77, 182 25, (1) 12, 853 (I) 237, 789 51, 823 18, 681 (1) 14, 349 309, 740 4, 000, 000 292, 961 368, 292 (l) 396, 591 107, 890 47, 459 111, 578 Netherlands Antilles and Surinam .................... 127, 500 35, 232 127, 500 28, 512 127, 500 42, 438 Netherlands New Guinea... 213, 158 , I) (1) I) (1) 252, 900 30, 151 274, 500 47, 774 270, 480 448, 284 162, 400 50, 630 162, 400 5, 006 162, 400 69, 723 , 000 27, 170 102, 000 25, 733 (1) 29, 873 (I) 18, 000 l) 445, 188 (1) 577, 086 428, 304 45, 968 428, 304 52, 108 428, 304 54, 330 , 000 37, 808 195, 000 55, 792 195, 000 58, 108 1, 145,300 81, 133 1, 171, 800 158, 365 1, 171, 800 165, 823 , 310 362, 000 1, 940, 370 640, 500 1, 961, 726 1. 043, 500 (l) (1) 53. 200 U) 53, (1) (l) 2, 643, 484 171, 600 2, 216, 937 (1) 250, 000 39, 640 250, 000 , 000 , 000 195, 44.3 (9 . (l) 60, 759 El; 2‘) 76, 000 19, 250 78, 000 13. 219 1 1) 11, 875 19, 160 11, 875 29, 586 11, 875 38, 340 1, 680, (I) (l) 162, 700 (1) 157, 500 (1) 41, 950 (l) 38, (9 80, (1) 4. (1) (1) (1) (9 (9 l) (1) 4, l) (1) (1) 31, 290 (I) 159, 766 1) 138, 922 1, 386, 500 3, 200 1, 386, 500 , 675 l, 386, 500 37, 533 See footnotes at end of table, p. 133. UNITED STATES AND WORLD HEALTH. ORGANIZATION 133 TABLE 6—G.—Eslimated government contribution. to malaria eradication progr ms in their countries for the years 1958, 1959, and 1.960, with estimated costs to W 0 (all funds)—Continue‘d 1958 1959 1960 Country Govem- WHO Govern- WHO Govern- WHO ment ment ment , Uganda ....................... $29, 400 $20, 400 $14, 000 $28, 992 $14, 000 $35, 417 Union of South Africa. _ - (l) (1) (1) ‘ 10, (1) (1) United Arab Republic. (3) 83, 000 967, 500 107, 272 El) 63, 702 Venezuela _____________ . 6, 773, 570 2, 070 (1) l) 1) (1) ietnam ............... . 802, 520 5, 000 856, 287 31, 783 866, 438 27,170 West Indies Federation . 609, 750 72, 530 603, 250 126, 120 581, 750 121,? 616 Yugoslavia ............ ... (1) ‘ (1) 529, 383 150, 000 1, 096, 810 60, Zanzibar ...................... 82, 614 53, 775 82, 614 53, 118 82, 61 56, 074 Total—countries ........ 50, 033, 162 5, 028, 640 49, 228, 291 6, 678, 097 54, 357, 140 7, 434, 090 Intercountry projects and inter-regional activities. . ............ 1, 493, 928 ............ 3, 106, 147 ............ 3, 616, 477 Grand total ............ 50, 033, 162 6, 522, 568 49, 228, 291 9, 784, 244 54,357, 140 11, 050,567 1 Information not yet available. TABLE 6~H.—-Malaria eradication special account [Contributions received during the years 1956—58] Countries 1956 1957 I 1958 Total $9, 901 , 134 95, 238 , 000 12, 601 12, 800 3, 819 1, 500 10, 000 4, 500 3, 012 35, 714 5, 000, 000 Vietnam ........................................................... 2, 000 Total ............................................ 5, 046, 003 83, 120 5, 197, 219 Sundry gifts ............................................ 1, 87l , Grand total ...................................... 5, 046, 909 84, 991 5, 199, 996 I To Oct. 31, 1958. Contributions offered, not yet received (as at Oct. 31, 1958): Cash contributions: Bulgaria ................................................ 1 $2, 206 Cambodia ______________________________________________ l, 000 Italy ................................................... 7, 200 Tunisia _________________________________________________ 2, 000 Total ________________________________________________ 12, 406 Contributions in kind: U.S.S.R. Contribution of 160 tons of technical DDT ____________ 3 82, 500 1 Contribution to be paid in 1959. I The value of $82,500 is that placed on this gift by the Soviet Government. 134 UNITED STATES AND WORLD HEALTH ORGANIZATION F. WHO STAFF In 1958, the WHO stafl" totaled 1,800, rounded to make allowances for normal fluctuations in personnel strength. Of these about 30 percent were in the headquarters in Geneva and 70 percent in the field, including the 30 percent of the total WHO staff located in regional oflices. The field staff is concentrated in underdevelo ed countries. See table 6—I and chart 6—D. Personnel costs inc uding personal al- lowances, absorb about 60 percent of the total WHO regular budget (see table 6—J). Costs associated with travel—such as duty travel, transportation of personal effects, travel on home leave, travel and subsistence of delegates, etc—absorb about 15 percent of the WHO budget. This is to be expected since one of the purposes of the organization is to make communication among individuals easier on a worldwide basis. The WHO staff is not highly paid by U.S. standards. The highest base salary for the secretariat~excluding salaries for five headquarters officials and six regional directors that are not in the standard sec— retariat schedule—is $12,500, income tax free, per year. In 1958, only 17 officials out of the total staff of 1,800 were paid at this rate. The WHO staff is recruited from every part of the world (see chart 6—13). In 1958, citizens of 60 countries were represented on the staff (table 6—K). This count excludes editors, translators, short-term consultants, stafl" locally recruited, the staff of the Pan American Health Organization, and staff on loan and Without pay. Unfortunately, the United States is underrepresented on the WHO staff—a problem due in part to the level of salaries which WHO is able to pay as compared with that for comparable professional work in the United States. TABLE 6—I.——Total WHO staff, by function, 1957—59 1957 1958 1959 Number Percent Number Percent Number Percent Headquarters: Central technical services _____________ 184 8.37 191 8. 15 197 8. 08 Advisory services ..................... 161 7. 33 158 6. 74 157 6. 44 Subtotal—operating services at head- quarters .......................... 345 15. 70 349 14 89 354 14. 52 Offices of the Director-General ........ 43 1. 96 43 1.83 43 1. 77 Administration and finance ........... 120 5. 45 120 5.12 120 4. 92 Subtotal-administrative services--- 163 7. 41 163 6. 95 163 6. 69 Total—headquarters ................ 508 23. 11 512 21. 84 517 21.21 All other: Regional offices ....................... 481 21. 89 504 21. 50 517 21.21 Advisory services ..................... 1, 209 55. 00 1, 328 56. 66 1, 403 57. 58 Total—all other ..................... 1, 690 76. 89 1, 832 78. 16 1, 920 78, 79 Grand total ......................... 2, 198 100. 00 2, 344 100. 00 2, 437 100. 00 TABLE 6-J.—-—Summary by purpose-of-expenditure code, indicating percentages of total regular budget estimates [Expressed in thousands] Organizational Operating program Administrative Total Percent e of total meetings services bu get 1957 1958 1959 1957 1958 1959 1957 1958 1959 1957 1958 1959 1957 1958 1959 Chapter: 00 Personal services .......................... $80 $92 $84 $4, 622 $5, 561 $5, 887 $691 $705 $716 $5, 393 $6, 358 $6, 687 43. 88 46. 87 46. 81 10 Personal allowances ................ l, 294 1, 791 1, 826 171 194 197 , , 98 , 023 ll. 92 14. 63 14. 16 21 Duty travel ___________________ 31 54 44 516 579 633 38 50 52 585 683 729 4. 76 6. 03 5. 10 22 Travel of short-term consultants __________ .. 285 367 360 ________ 2 2 285 369 362 2. 32 2. 72 2. 54 23 Travel on initial recruitment and repatria- tion _____ 286 183 189 8 10 9 294 193 198 2. 39 1. 4.2 1. 39 24 Travel on home leave. _ ______ 210 323 406 32 26 43 242 349 449 1. 97 2. 57 3. 14 25 Travel and subsistence of delegates 98 109 109 178 177 165 ________________________ 276 286 274 2. 24 2. 11 1.92 26 Travel of temporary stafl __________ 30 28 27 44 55 58 - 74 83 85 . 60 . 61 . 60 27 Transportation of personal effect ______________________ 43 21 21 12 4 4 55 25 25 . 45 . 18 . 17 30 Space and equipment services..- 10 12 11 154 134 135 48 43 42 212 189 188 1. 72 1. 39 1. 32 40 Other services _______________ 22 21 20 282 292 295 53 56 57 357 369 372 2. 90 2. 72 2. 60 50 Supplies and material 99 89 98 599 473 455 120 99 62 818 661 615 , 6. 66 4. 88 4. 30 60 Fixed charges and claims ________ 1 1 65 66 66 2 7 8 67 74 75 . 55 . 55 . 52 70 Grants and contractual tech ________ 1, 921 1, 605 l, 873 ________________________ l, 921 l, 605 1, 873 15. 63 11.83 13. 11 80 Acquisition of capital assets. ___________ 5 1 1 1 143 4 3 3 247 152 147 2. 01 1. 12 1.03 Contingency provision. ________________ 85 85 ________________________________ 85 85 ........ . 63 . 59 Other purposes—Reimbursement of work- ing capital fund. _ 100 100 ________________________________ 100 100 ........ . 74 . 70 Total ................................. 375 407 395 10, 737 11, 960 12, 697 1, 179 l, 199 l, 195 12, 291 13, 566 14, 287 100. 00 100. 00 100. 00 NOILVZINVDHO I-IL'IVEIH G'IHOAA ([NV SHLVLS (IELHNQ 981 136 UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE 6—K.—World Health Organizatiow—Geographical distribution of staflr 1950—58 [Excluding language stafl, short-term consultants, stat! Eocally recruited, on PASB roll, on loan andwithout pay 1951 1952 1953 1954 1955 1956 1957 1958 3 4 5 6 5 12 9 12 4 s 12 14 12 13 11 13 4 6 7 6 1o 10 8 7 7 10 10 1o 12 10 1o 1 1 2 3 4 6 5 2 1o 9 9 12 2o 21 2; 1 ........ 1 28 41 43 45 51 47 50 4s . 4 5 4 3 3 2 3 2 7 9 11 7 16 18 16 15 9 10 12 13 14 13 12 15 ______ 4 5 5 3 5 4 5 5 2 2 1 2 1 1 1 1 1 ........ 1 2 3 2 1 2 2 2 1 1 1 , 2 2 30 4o 42 41 30 39 4o 47 . 2 5 2' 5 6 5 4 19 15 15 21 21 (a) 1 1 1 ................ 1 3 3 3 4 4 2 45 39 45 48 44 51 3 6 7 10 12 1s 9 7 12 12 15 1 1 2 3 4 5 1 1 1 1 1 Rumania" 7 Saudi Arabia . _. Spain. __________ 1 2 2 3 3 7 8 2 4 Sudan. 1 1 ........ Sweden- 3 8 10 10 9 11 14 8 8 Switzer 14 17 19 26 27 30 37 39 49 Syria..- ....... 1 __-.-_-. 2 2 1 3 4 0) Thailan _ l 2 1 l 1 ’l‘lmlsia .. Turkey 2 Bee footnotes at end of table, p. 137. UNITED STATES AND WORLD HEALTH ORGANIZATION 137 . TABLE 6—K. —World Health Organization—Geographical distribution of stafl' 1950—68—Continued Country 1950 1951 1952 1953 1954 1955 1956 1957 1958 Ukrainian S S R _- . ......... _ -. Union of South Africa ______ 4 4 10 ll 9 12 10 6 8 U. S. S. R ................... 2 l 2 United Arab Republic ------ (4) (‘> (4) (4) (9 (‘) (‘) 0) 23 United Kingdom. _ _ 37 91 118 129 135 158 168 159 189 U. S. A._.__._-__ 79 110 105 99 106 99 103 107 Uruguay.. ........ _ 1 _ 2 ........ Venezuela ________________________________________________ 2 1 1 1 Vietnam _ ........ Yemen. _ _ _ _ ........ _ ‘1 ugoslavia 1 1 1 2 2 5 4 6 9 stateless" ................ l 1 1 4 2 4 1 Total ................. 255 471 621 677 675 750 803 815 932 I Nonmember state. 3 See United Arab Republic. ' Associate member state. ‘ Séc Egypt and Syria. Source: Personnel section of WHO, Geneva, Nov. 19, 1958. 88516—59—10 CHART 6-D DISTRIBUTION OF STAFF av WORK LOCATION . 88I NOILVZINVDHO HIL'IVEIH (I'IHOAA (INIV SEIILVILS (KILLINII Cum 6—E ‘ onsmaunou OF PROFESSIONAL STAFF av NATIONALITY \ a pun-In, u n...“ § min-~51" «.- m. It wan-rm: M hi-Inmmlluudmlm _wmmn~namu wlnw-thw-wdwufl NOLLVZINV‘DHO HL’IVEIH (I'IHOM (INV SHLVLS (IELLINB. 68I 140 UNITED STATES AND WORLD HEALTH ORGANIZATION G. FUTURE FINANCIAL NEEDS AND PROGRAMS The United States, like other powers, with relatively strong financiaI capacity, must determine how far and how fast it is prepared to go to bolster WHO’S efforts by enabling the organization to enter signifi- cantly into new or enlarged fields of activity. The number of relatively new areas of possible substantive action is considerable. Proposed eradication of smallpox is one such area; a massive assault for improved water systems and against gastroenteric (diarrheal) disease is another. Water systems The latter offers excellent illustrative possibilities as to the challenge and the financial dilemma. At the World Health Assembly in Minneapolis in May 1958 the nations resolved in favor of increased emphasis on worldwide com- munity water supply efforts. Clean water is obviously a key to a better, healthier life throughout the globe. It should be noted that the broad array of preventable gastro- intestinal (enteric) diseases includes those transmitted by water (typhoid, cholera, etc), the diarrheal diseases and other diseases contact-transmitted through inadequate personal hygiene. It is estimated that the latter group annually amounts to some 500 million disabling illnesses and 5 million infant deaths worldwide. Broad-scale improvement in environmental sanitation is essential for this and other purposes. ‘ In the proposed U.S. budget for the 1960 fiscal year it is recom- mended that our Government strengthen international efforts in the field of water supply and sewerage. . Stronger bilateral efforts b the International Cooperation Adminis- tration and support of multifateral aid through WHO and PAHO are contemplated. These specific proposals are, in my judgment, sound fields for expanded U.S. effort. v Yet it is manifest that overall decisions on them cannot be pred- icated on (a) 1 year or 2 years of future planning, or (b) by the United States alone. If We are to enter into bold, long-range efforts—- as I, for one, believe we should and must—we and others must open our eyes wide to the hard financial facts of long-range need. For example, to train indispensable sanitary engineers in the de~ veloping nations is one thing; to secure massive funds to enable the engineers actually to construct, install, and maintain new water and sewerage systems some years hence is quite another. , The Congress should, therefore, make its decisions and time its actions accordingly, as should comparable decisionmaking bodies in those other nations which have the financial ability to join with us. Specifically, consideration must be given to exactly which sources are prepared to advance sums of money for capital construction of water and sewerage projects, with appropriate terms of interest and repayment. UNITED STATES AND WORLD HEALTH ORGANIZATION 141 Problem of sources of funds Meanwhile, the sources of WHO finances represent problems which should have the attention of all those interested in the organization. Some of these problems consist of: F (a) The uncertainty of allocations based on varying distribu- tions from United Nations expanded technical assistance funds, supplementing the regular budget. (b) The trend toward separation from the regular budget of special and separate accounts for the purpose of meeting specific problems such as malaria eradication or expanded research. (0) A current fact of overreliance upon the United States as the source for contributions to these special and separate accounts. The question of the varying future levels of the UNETAP distribu- tions goes to the heart of the problem affecting emerging areas of the world, generally. It involves considerations of policy such as what, at each stage, (a) the industrialized powers are prepared to contribute and (b) what should be the highest specific priorities in assisting these emerging countries. The Iatters’ needs remain so diversified and so pressing as to merit the best thinking of all nations. Problems of health and standards of living are inevitably intertwined with prob- lems of food productivity, industrialization, and overall population, together with a host of other factors. These enter, too, in weighing the ultimate impact of such special purposes of WHO as malaria eradication. Meanwhile, the separation of special accounts poses fiscal dilemmas of its own. In considering the separate accounts, we note that the various nations tend to varying degrees, and with varying resources, to be interested along certain lines. No nation has had broader interest than the United States. We ourselves have, however, desig- nated special sums for special purposes which we tfelt to be in the best interest of mankind. US. contributions The disparity is clear between the respective percentages of US. funds in relation to the world totals in these categories: (a) The US. assessed contribution to WHO’S regular budget (under 33 percent); (b) U.S. voluntary contributions to the United Nations Ex- panded Technical Assistance Program (now 40 percent) and (c) U.S. voluntary contributions to WHO’S special accounts (where we are carrying 95 percent of the burden in the case of malaria). I found WHO officials keenly concerned about these problems, es- pecially about the almost total reliance on U.S. funds for the malaria eradication special account. .Every efl’ort, I was assured, has been made to encourage other nations’ financial support. It is understood that some consideration has been given toward proposing the joining of the separate special accounts into an overall voluntary account. In that way, for example, a country which would allocate funds or materials in kind for one special purpose could clearly receive appropriate “credit” in relation to sums or donations in kind from another country for a different specialized purpose. 142 "UNITED STATES AND WORLD HEALTH ORGANIZATION Whatever the fiscal mechanism, which ultimately is worked out, the important oal is that as many countries as possible share in the task of meeting HO’s growin needs. WHO has always recognized the value of a large number 0 countries however limited their resources making available sums proportionate to their capacity, even though the total of such sums may not aggre ate very large in the overall finances of the organization. It shoul be noted that the increase in the number of small nation contributions for these special purposes is to be commended. It is hoped the list will continue to grow with the years. The task is not easy. Many emerging countries are already under considerable strain to to fulfill present assessments. Despite this fact, the very modest amounts of arrears is a testament to these nations and to WHO. Inflation, however, continues to raise havoc with national and inter- national budgets and rograms. It is essential, therefore, that feasi- ble ways be devised or a breakthrough despite obstacles to higher financial ground. US. leadership in WHO and PAH 0 So far as What the US. attitude at the present time should be, it appears that in this circumstance, what is needed fiscally is not a rigid slide rule approach by the United States, in determining the level of its future financial support to these special programs. Any such impatience and inflexibility on our part would prove contra- productive to our goals. Leadership by the United States has always entailed a generous Willingness not only to be first and preeminent in meeting a need, but to remain first for a reasonable time in sustaining the response to the need. Problems of standards of living with which we and others are coping have been centuries in the making; they will be long in resolv— ing. In its contributions to the Pan-American Health Organization, the United States has Wisely not hesitated to provide what appears at first glance to be a very hi h percentage of the contributions in order to meet the heavy nee s of this emerging area. While the relative percentages may seem high, the absolute amounts for PAHO and WHO are modest indeed in comparison to other US. budgetary commitments. Here in the Western Hemisphere, PAHO has written a record of achievement which should be a source of deep pride to every inhabi- tant of the New World. On a global basis, WHO, often emulating past PAHO pioneering or otherwise writing bold new chapters of its own has amply repaid America’s and the world’s investment in it. Possibility of novel approaches It should be noted that from time to time, WHO has considered various proposals of ways and means of raising special funds to aug- ment the regular income of the organization. Several imaginative approaches have been reviewed and at least one (for voluntary pur- chase of World Health Seals) was tested for several years before disContinuation. Past unsatisfactory results should not however deter the nations from seeking to come to grips with the financial problem in a new resourceful way. ' UNITED STATES AND WORLD HEALTH ORGANIZATION 143 Other countries’ contributions In any event, the United States is entitled to ask that other nations with relatively strong financial capacity face up to their own voluntary obli‘ ations toward the world’s growing health needs. 0 oflicials take pride and rightly so in the community of genuine participation among the respective nations. Participation is evidenced in many ways, for example, in each country’s contributions of its nationals to the staff, to consultants, to finances and accommo- dations, its donations in kind, and by other means. Even fuller and more universal participation should be continually encouraged. United States and USSR. contributions It is not inappropriate at this point to return to reference to the financial roles of the USSR, and of the two still “inactive" non- paying states, Byelorussia and the Ukraine. By way of further background to the significance of the respective countries present and possible contributions, the following tables 6—L—M—N might be considered. Comparison should be noted in the percentages of the United States as compared with the three Soviet states’ contributions— (a) on assessment; (1)) to special projects; (0) to United Nations expanded technical assistance funds obligated by WHO. The facts speak for themselves on the disproportionately heavier contributions made by the United States. TABLE 6—L.— US. and Soviet contributions to the World Health Organization WHO U.S. contribution U.S.S.R. wn- Byelorusslan con- Ukrainian con- assessed tribution tribution tribution contribu- tion to budget Amount Percent Amount Percent Amount Percent Amount Percent 38. 29 9 $295, 829 6.09 3 $10,107 0. 21 ‘ $39, 263 0. 81 38. 54 304, 945 6. 13 10, 418 . 21 40, 472 . 81 36.00 5446,772 6.38 015,265 .22 059,296 .85 35. 00 0 450,333 6. 35 0 15, 386 . 22 5 59,768 .84 33.33 0 553, 045 6. 43 0 18, 896 . 22 0 73, 401 86 33. 33 0 532, 808 5. 93 6 18, 203 . 20 0 70, 714 . 79 33. 33 5 531, 788 5. 93 0 18, 169 . 20 5 70, 579 . 79 33. 33 0 594, 550 5. 92 ,330 .20 5 78,980 .79 31. 64 845, 480 7. 84 0 29, 590 . 27 0 112, 440 1. 04 29. 96 1, 272, 460 9. 86 ° 45, 010 . 35 6 168, 780 l. 31 32. 38 1, 593, 700 11. 06 6 55, 490 . 38 0 210, 850 1. £6 31. 70 l, 916, 060 12.80 0 65, 260 . 44 0 252. 910 1. 69 Total.-- 113, 584,346 37, 665, 911 ........ 9, 337, 770 ........ 322, 124 ........ 1, 237, 453 ........ 1 Includes $650,354 working capital fund advance. 3 Includes $103,389 working capital fund advance. 3 Includes $3,532 working capital fund advance. ‘ Includes $13,722 working capital fund advance. 5 Working capital fund advances not included. ’ 0 Full years of inactive membership. Countries resumin active status must pa 5 percent of their assessment during full years of inactive membership and 00 percent during part a] years of hective membership, over a eriod of 10 years. The U.S.S.R., Ukraine, and Byelorussia became inactive members during 1949. In 19 , the Soviet Union resumed active membership. The other two. so far, have not. 144 ,UNITED STATES AND WORLD HEALTH ORGANIZATION TABLE 6—M.—Contributions to special projects of the World Health Organization by the United States and Soviet Union ‘ United States: 1958 Malaria eradication _________________________________ $5, 000, 000 1958 Research study _____________________________________ 300, 000 1959 Malaria eradication _________________________________ 3, 000, 000 Total ___________________________________________ 8, 300, 000 Soviet Union: 1958 1,000 tons DDT preparations ________________________ 82, 500 1958 25 million units of dry smallpox vaccine ________________ l 285, 000 ‘ l The value of $285,000 is that placed on this gift by the government. TABLE 6-N.—United Na ‘rms rcpanded program of technical assistance funds at Work» World Health Organization a: .. and Soviet participation I] U.S. contribution U.S.S.R. con- Byelorussian Ukrainian con- Amount tribution contribution tribution Year obligated by WHO Amount Percent Amount Parr-em Amount Percent Amount Percent $1, 337, 011 $802. 207 00. 00 4, 353, 970 2, 640, 683 60. 65 4, 178, 806 2, 390, 277 57. 20 $187, 211 4. 48 3, 754, 545 2,080, 018 55. 40 150, 182 4.00 $7, 509 0. 20 $18, 773 0. 50 4,400,256 2, 385, 819 54.22 158, 849 \3. 61 7,920 .18 19,801 .45 5,184, 538 2, 592,269 50. 00 179,903 3.47 8,814 .17 22,294 .43 1 7 5,204,666 2, 578,392 49. 54 168,631 3.24 8,327 .16 21,339 .41 1958 (estimate) ...... 5,462,000 2, 457,900 45.00 174,238 3.19 8,739 .16 21,848 .40 1959 (estimate) ______ 5, 456, 400 2, 182, 560 40. 00 181, 698 3. 33 9, 276 . 17 22. 917 Total ........... 39,332,192 20,110,125 _. ...... 1,200,712 50,585 126,97 I As country contributions are not earmarked for specific agencies or projects, the amounts shown are the percentage shares of the U.S. and Soviet contributions to the total expanded program central fund related to amounts obligated by WHO. Therefore, these amounts do not reflect actual dollars or rubles obligated by WHO for each year. H. CONCLUSION The sums mentioned above do not constitute the tiniest fraction 0 ‘ the billions of dollars which both the Soviet Union and the United States are spending in their programs for the conquest of outer space. Man may reach other planets, but 2% billion human beings and more Will still be on earth. And the problem of disease will still weigh heavily upon them. ' Financial resources are somehow always found by the nations for their armed forces and for military—related projects. But medicine throughout history has never been as well financially endowed. In the 20th century, for the first time, mankind has begun to strike a slightly better balance between What is spent for possible destruction and what is spent for healing. But the balance is still heavily one sided in favor of arms. It will no doubt continue to remain so. Maintenance of world peace is of course, crucial; security for survival indispensable. But reasonable security against disease is likewise vital. The World. Health Organization helps provide such security. Its record of achievement, reflected in the preceding pages, stands for all mankind to behold in pride. Its record has transformed literally hundreds of millions of lives for the better. No financial value—in dollars or rubles or pound sterling or francs—can be set, in reckoning WHO’S tangible and intangible contributions. UNITED STATES AND WORLD HEALTH ORGANIZATION 145 But pride and admiration for past achievements are not enough, in the face of still unfulfilled need. Expanded resources for healing must now be found. These are, in a certain sense, resources or “war.” It is the only war mankind desires—war against its ancient enemy, disease, war in Which all countries fight on the same side. For the first time in human history, this war, at least against in- fectious diseases, can be virtually won. The enemy micro-organisms will no doubt fight back, in new forms, new species. But the toll taken by the micro-organisms in the form of vast amounts of avoidable human pain and suffering can definitely be reduced. The choice therefore, confronts mankind: Adequate or inadequate resources for healing, limited skirmishes against disease or massive assaults, a quest for modest gains or for large-scale victories. May mankind’s decision be adequate to the challenge. 0 ’3?” . ii; a’ ,3 us. BERKELEY LIBRARIES ' . lllt‘li‘lllllfl (032335152