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World Health Organisation

Health for All: Some Critics Less Critical

THE meeting of WHO’s European regional committee inCopenhagen on Sept 14-20, with Sir Donald Acheson, chiefmedical officer of the Department of Health and SocialSecurity, London, in the chair, was perhaps a little too calm.At times one would like to see more than silent criticism of

governments who condone, protect, and live off industrieswhich directly damage health.

It was a WHO budget year and, in view of the hostileatmosphere across the Atlantic, contingency plans had beenmade for battening down the hatches. President Reagan isreported to have seen the error, or at least the disadvantages,of the position he and Congress had adopted, so the future ofWHO’s finances might not be as bleak as hitherto, thoughthe fall in the dollar is a fact. There has never been any doubtthat WHO would stay on its Health For All (HFA) course.As the European regional director, Dr Jo Asvall, said, it is aprogramme that people can understand, it is relevant tothem, and it releases their energy. It strikes a deep note ofconsensus and downright enthusiasm.The HFA campaign is beginning to win over some of its

greatest critics. The medical schools and universities, forexample, have been wary of the HFA approach, which takeslittle account of professions and their traditions. But nowsome of those who are carefully scientific in their approachand who are wedded to the importance of medicine areseeing that health might have other legitimate components.The chairman of the research advisory committee, Prof T.Fliedner (Ulm), for example, is a radiation scientist, yet nowhe is planning to involve the Association of Medical Deansin reorienting medical education, and indeed research,towards the wider HFA approach. Those who pay thepipers call the tunes, however, nowhere more than inresearch.There is a growing understanding that lifestyles in

Europe cannot be changed without influencing other partsof society (what WHO calls "intersectoral" activity). Thedirection and magnitude of the shift which HFA requiresmake it clear that major policy debates are needed. Finland,Yugoslavia, Poland, and the Netherlands have nationalHFA strategies. Hungary and Bulgaria are implementingtheir first five-year plans. Norway and Ireland are holdingmajor planning conferences on health rather than healthservice strategy. The United Kingdom has no such nationalplan, though, as in Germany, districts and regions havestarted testing the HFA strategy as a framework for theirplans.

So why, when the groundswell of interest in HFA isgathering momentum, has the European office taken theeasy course of choosing tobacco and health, already perhapsthe most closely studied health problem, as the focus of itsattention? Has WHO made the move from vertical and

specific programmes to health planning across the board-or not? At best, tobacco is a classic example of the needfor the HFA intersectoral/public participation/lifestyleapproach. There is a very special international and intersec-toral role for WHO in the fight against the production andmarketing of tobacco-and drugs and alcohol. But will theEuropean region fight shy of its international responsibilityto stop Britain and other countries exporting disease to thedeveloping world?

Unless WHO’s European information departmentchanges its approach, HFA may be seen as a long andexpensive way to plan a rather familiar campaign againstsmoking. The press coverage arising from one of WHO’sfew attempts (which emerged during this regional meeting)at holding a press conference will tell.

A Year of Emergencies1986 had also been a year in which WHO has demon-

strated its usefulness in international emergencies-notablyon AIDS and Chernobyl. AIDS has moved from an exoticmedical event to a grave public health issue. The highestincidence rates per million inhabitants in Europe were inSwitzerland (15-4), Belgium (14), Denmark (13-3), France(10-4), Luxembourg (7-5), the Netherlands (6-8), and theFederal Republic of Germany (62). By May 15, 1986, thetotal number of AIDS cases in Europe officially reported toWHO had reached 2423. There are probably 50-100antibody-positive persons for each clinical case. So between150 000 and 250 000 people in Europe may have beeninfected. Between a quarter and a third may be expected todevelop the full syndrome. 67% of clinical cases werehomosexuals or bisexuals, 7% intravenous drug abusers,3% haemophiliacs, and 2-5% transfusion recipients. In15% no known risk was identifiable.The Director-General of Health in Israel reported that in

one case transmission of the AIDS virus had been tracedback to 1979. He wanted education on AIDS to becombined with contraceptive education for teenagers. If thefigures were analysed more carefully it might be possible toidentify workplaces, such as theatres and studios, wherehealth education could be carried out. He also pointed to thedanger of transmission by bisexual men who visit prosti-tutes. There was fear that the free supply of needles to drugabusers might promote the habit of injecting and that thebetter course of action could be an increase in facilities for

drug abusers who sought help.The deputy chief medical officer of the Republic of

Ireland reported that 34% of intravenous drug abusers wereHIV positive. He did not know how to deal with theproblem since "people will not act responsibly under theinfluence of heroin". The appropriate legal framework forAID S had yet to be worked out. Delegates asked what actionshould be taken against infected people who knowinglyinfected others; what were the rights of individuals not tobecome infected?; and what were the rights to care for thosewho were ill?

Serological surveillance was improving all the time, andeasier tests were being developed, but the French delegationraised doubts about the usefulness of widespread screeningwhen no treatment was available. The director of the AIDS

programme at WHO headquarters, Dr Jonathan Mann,reported that no vaccine for widespread use could beexpected in the near future. He was particularly anxiousabout vertical transmission in Africa, where AIDS affectedmen and women in equal numbers. He asked the Europeanregion to continue to give both human and materialresources to help "countries which face a problem whichdwarfs your own". But Dr Mann thought we should notoverestimate the extent of our own ignorance: in a

remarkably short time we had learnt enough about thetransmission of the disease to implement successful publichealth strategies.The accident at Chernobyl power station saw the WHO

regional office at work day and night sifting masses of