International Aspects of Maternal and Child Health: Variation in

International Aspects of Maternal andChild HealthVariation in Problems with Differences inTechnical DevelopmentLOUIS J. VERHOESTRAETE, M.D,, M.P.H.

' The present communication attemptsto contrast problems of maternal andchild health in those countries, limitedin number, that have reached satisfac-tory levels of technical developmentwith those at much lower levels. Thisseems justified, rather than to discusscountries at various levels of technicaldevelopment, because of the enormous

disproportion between these two differ-ent groups. Indeed, only one-fifth ofthe world's population 14 live in areaswhere the known infant death rate islower than 50 deaths per 1,000 livebirths. Another fifth live in areas withrates between 50 to 100; while at leastthree-fifths of the world population livein areas with rates known or estimatedto exceed 100 per 1,000 live births.Furthermore, the figures for many ofthe less developed areas are based on

grossly incomplete reporting and we

may assume that the true rates are even

higher.Children represent a major portion

of the world population, of which ap-

proximately 35 per cent are under 15years of age. The divisions by age,

19

shown in Figure 1, give a rather strikingpicture of the contrast between devel-oped and less developed areas. Thelatter have a much younger populationwith around 40 per cent under 15 years;while in the more developed countriesthe figure drops to 25 per cent, as theolder population increases. These figuresare influenced strongly by the differencebetween crude birth rates and deathrates. In the most developed areas thereare roughly 20 births and 10 deaths per1,000 population, a natural addition tothe population of 10 per 1,000 eachyear. In the less developed areas thefigures are roughly 40-50 births and20-30 deaths per 1,000 or an additionof about 20 per 1,000.

In Figure 2, showing the percentagedistribution of deaths in the various agegroups, the contrast in wastage of livesin childhood is even more striking.There are some sizable differences be-tween the three continents, althoughthese are obviously affected by the

Dr. Verhoestraete is medical officer, adviserin maternal and child health, Pan AmericanSanitary Bureau, Regional Office of the WorldHealth Organization, Washington, D. C.

This paper was presented before a JointSession of the Food and Nutrition, Maternaland Child Health, and Public Nursing Sec-tions of the American Public Health Associa-tion at the Eighty-Third Annual Meeting inKansas City, Mo., November 15, 1955.Acknowledgment is made of the valuable

assistance of the Epidemiology and StatisticsSections for the analysis and presentation ofdata.

Some of the broad principles sostrikingly delineated in this world-wide comparison of well developedand disadvantaged countries maybe found usefully adaptable andapplicable to the economically lessfavored areas of our own UnitedStates.

20 JANUARY 1956 AMERICAN JOURNAL OF PUBLIC HEALTH

FIGURE

quality of available data. However, inspite of these disparities, the differencesin the proportion of deaths below 15years are enormous. Furthermore, thechart shows strikingly the excessivechild loss in the age group from one tofour years in the economically less de-veloped areas, far greater than might beexplained by the differences in age dis-tribution of the total population. Whatreally retains the attention are the very

low figures of child loss in these age

groups for the developed countries. Thishelps us to understand the enormous

difference in expectation of life underthese two different sets of economic con-

ditions, for expectation at birth isaround 68 years in the most developedcountries and approximately 30 in theleast developed areas.

An interesting example of parallelismbetween time and geography is shownin Figures 3 and 4. Figure 3 illustratesthe distribution of age-specific deathrates in the Netherlands 5 at four inter-vals within the last 45 years. The steadyimprovement, reflected throughout thelife span, has been parallel to general

economic betterment, higher standardsof living, improved health conditions,and great advances in medical knowl-edge and public health organization.Figure 4 shows similar distribution ofage-specific rates for four selectedcountries in the Americas 3, 6 at variousstages of development. The similaritywith the previous figure is obvious. Onecannot stretch the comparison too far,but it is not unfair to assume that whathas been achieved in the Netherlandswith the passage of time may also beforeseen in the three Latin Americancountries.

Figure 5 gives the trend in bothmaternal and infant mortality for thelast 40 years in three more developedand three less well developed coun-tries."' 6-12 The most striking fact isthat for both maternal and infant mor-tality the changes in the trends for thesecountries run approximately parallel,but at quite different levels. A signifi-cant point, however, is that around1935 there was a definite change inthe trend of the maternal death rates,whereas no such change was observed

FIGURE 2

AGE DISTRIBUTION OF WORLD POPULATION BY RECIONSACCORDINC TO RECENT CENSUS OR ESTINATE

.... ......~ 5'..

..t.zca uS .. a

MATERNAL AND CHILD HEALTH VOL. 46 21

FIGURE 4

DEATHS PER 1,000 POPULATION BY AGE GROUP FORFOUR SELECTED COUNTRIES OF THE ANERICAS,1952500

300

200

01

05

03

02

0 10 20 30 40 50 60 70 80Age

in the infant death rates. We knowthat the change in the trend of maternalmortality was true in the more devel-oped countries, although to a variabledegree, in all three major causes ofpuerperal deaths-infection, hemor-rhage, and toxemia-and was con-

comitant with great advances in chemo-therapy and antibiotics, with betterorganized and more extensive prenatalcare and with improved childbirth prac-tices. The same kind of improvementin total maternal mortality is also seenin the three less well developed coun-

FIGURE 5

MATERNAL AND INFANT DEATHS PER 1,000 LIVE BIRTHS FOR SIX SELECTEDCOUNTRIES OF THE WORLD, 1910 -1952

MATERNAL 400 INFAIC

06- ~ ~-SWEDEN - 20)

100

81

60

.-.CHILE.- CHILECOLOMBIA *H ~~~~~~~COLOMBIA

08 MEXICO --mExiCO-AUSTRALIA AUSTRALIA......... UNITED STATES AIE TTS ___

06 SWEDEN 20 - - SWEDEN

04 1 I .I -3 ..1L1910 1915 1920 1925 1930 1935 1940 1945 1950 1910 1915 1920 1925 1930 1935 1940 1945

reAsJ rA

FIGURE 3

DEATHS PER 1,000 POPULATION BY ACE GROUPFOR THE NETHERLANDS FOR FOUR PERIODS

NT

-I

1950


tries, but is not paralleled in infantmortality. This is not surprising, sincethe causes of infant mortality are morevaried and less susceptible to specificand direct public health attack in theabsence of general social and economicimprovement.

Figure 6 shows the changes for Chile 8and the United States 12 in mortalityunder one month, one to 11 months,and one to four years, for the period1900-1952. Chile is one of the twocountries of comparison selected be-cause of its relatively reliable statistics,although many areas of the worldprobably are more representative. Thefact that the mortality from one to fouryears in Chile is still at the level of themortality under one month for theUnited States reflects the great differ-ence in the conditions existing in thesetwo countries. Furthermore, in theUnited States the neonatal mortalityhas long outgrown in importance themortality from one to 11 months andhas become the outstanding problem.In Chile, on the contrary, the mortality

FIGURE 6

of from one to 11 months is still farabove the neonatal mortality, thus indi-cating the need for further attack onthe major causes of infant mortalitythat can be more easily reduced. Fin-ally, the steep decline in the mortalityof one to four years in the United Statesshows that under increasingly favorablecircumstances the causes responsiblecan be almost completely eliminated.

Another way of examining this con-trast is to compare the ratios of thedeath rates in the first year to those inthe next four years of life, shown inFigure 7. In the United States, for ex-ample, the ratio is 20-1, while in acountry like Ceylon it is only 3-1. Theratio becomes greater as both rates arereduced, thus supporting the deductionthat mortality between one and fouryears is more readily reducible.The maj or causes of death in these

two age groups are further analyzed inFigures 8 and 9. The great reductionin countries of low mortality for agesfrom one to four has come in all majorgroups of causes-gastrointestinal dis-eases, respiratory diseases, infectiousand parasitic diseases-all readily pre-ventable and essentially dependent onenvironmental circumstances. The pic-ture of infant mortality is a differentone. Here, the same causes of mortalitywhich can be controlled throughchanges in the environment have alsobeen equally reduced in the developedcountries; whereas causes responsiblefor neonatal mortality have only par-tially been diminished.The extent to which environmental

factors influence the mortality of se-lected age groups is strikingly illustratedby Figure 10, showing the changes inthe Netherlands 5, 13 on various portionsof child mortality as a result of theextremely poor conditions which devel-oped in the last five months beforehostilities ceased in Western Europeduring World War II. The strikingfactor is that mortality under one week

DEATH RATES UNDER ONE MONTH, 1-11 MONTHS, 1-4 YEARS,FOR CHILE AND UNITED STATES, 1900-1952

MATERNAL AND CHILD HEALTH VOL. 46

FIGURE 7

was practically unchanged; whereasmortality in the other age groups andparticularly those from one to threeweeks, one to 11 months, and one tofour years was substantially raised.Thus the mortality between one to 11months was augmented well above theneonatal mortality, setting the Nether-

FIGURE 8

' Calcultlon for causer based on 1950-51 distribution of deaths |

lands back in its infant mortality to thelevel of 25 years earlier.

Figure 11 illustrates further the im-portance of specific aspects of thegeneral program on changes in infantmortality in Mauritius,14 an island inthe Indian Ocean with a population ofapproximately half a million. Intensive

FIGURE 9

JNFANT DEATS-ER 44O LtVE SIRIUS AID BEAM PER 4.0 PIPULATIU-0 ME CRIHOUP, I4YEARS FOR 10 CNTRIESIF TE IO.D1 i2t

f a- . 1

. Zf#, ~- .mW l"Winhes meoformhew --.

hI.Ejews-O OSN~.IM

DEATS PER 1,0 POPULATION IN AGE CGOP 1-4 YEARS.BY CAUSE, FOR SIX SELECTED COUNTRIES OF THE WRLD,

1950-1952 AVERACE

= ILL-DEFIDED AND UNNIM OTHER SPECIFIED

lNlFU1E(VE AND PARAS

ESPIRATORY

MIULftTMAFRAIN

INFANT DEATHS PER 1,000 LIVE BIRTHS, BY CAUSE,. FOR SIX SELECTED COUNTRIES OF THE WORLD,

1950-1952 AVERACE

m

23


FIGURE 10

DEATH RATES UNDER ONE WEEK, 1-3 WEEKS, UNDER ONE MONTH, 1-11 MONTHS,UNDER ONE YEAR, 1-4 YEARS FOR NETHERLANDS AND UNITED STATES,1900-1952

200 200NETHERLANDS UNITED STATES

100 100 Under one year

Under 'I year i months.50-Uwdet / yeo<_s afiUnder I month

Un7der Iweek StS5S~~~~~~~~~~~~~~~~~~~~~ietUne no -*ll

-3 weeks

v- 5 ~~~~~~~~14 years14 year

1900 1910 1920 1930 1940 1950 1900 1910 1920 1930 1940 1950YEA R r r #

and specific attacks on malaria resultedin a spectacular decline. Concomitantlya decline of substantial proportions isseen in infant mortality; whereasdiarrhea and enteritis also show some

decline but not as great as in the totalinfant mortality. Since it is known that

FIGURE 11

the malaria program was the onlyserious change in the public health andmedical services during this period itwould seem that this is another exam-

ple of beneficial effects of a specificprogram on infant mortality.

Finally, in Figure 12 the possible

FIGURE 12

BIRTH AND DEATH RATES,NAURITIUS, 1930-1953 AWERAGE TOTAL, ANIMAL AND MILK PROTEININTAKE BY REGIONS OF THE WORLD, 1953-1954

100 MkpoeTotal p,oten

a 75 ....~-0 a oel

AM*ERICA AK)U.S. EAST AIIDN.Z. EUOE

Sewce Ii,. Stet ,I food s14 A9.calure 1955, FaO UniMe Nt..e


relationship of the facts already shownto malnutrition is suggested in the dis-tribution of total protein consumption 15and particularly of animal and milkprotein for areas of the world. Thisgives some idea of the great disparityin the amount of available animal pro-tein and particularly of milk. It permitsone to understand the difficulties whichoccur in many areas during the weaningand postweaning periods and the de-velopment of protein deficiency disease,kwashiorkor. This situation is probablydirectly responsible for a portion ofinfant and early childhood mortalitynot acknowledged in the present statis-tical data of the causes of death and iscertainly an important debilitating factorpredisposing the infant and young childto the effects of the other major diseasehazards.

Discussion

From the preceding data it seemsobvious that in less developed areas theapproach to increasing survival of thechild population is closely linked tothose programs that, over and abovepersonal advice to the mother and thefamily, will aim at control of maj orcommunicable disease, and at improve-ment of basic sanitation and of nutri-tion. Ultimately, this is part of, anddependent on, a broad program of com,munity development. While emphasis,therefore, will be on measures aimingat an increase in the survival of childrenbeyond the neonatal period, these pro-grams will, of course, also promote thesurvival of infants at any age succumb-ing from the same causes of death.

In contrast with this, the technicallydeveloped countries have programswhich, with the disappearance of theproblems mentioned before, aim essen-tially at control of developmental fac-tors and of factors related to accidentsof pregnancy and childbirth. In fact,in those countries the maternal and

child health programs are focused onthe perinatal period and are directed atsaving more infant lives by preventivemeasures during pregnancy and at thetime of childbirth. Such programs pre-suppose the existence of advanced gen-eral public health and specific maternaland child health services, and availabil-ity of highly skilled specialists, facilities,and technics, as well as -the higherbudgets which they require.One must not forget, however, that in

the economically less developed coun-tries the portion of the perinatal mor-tality due to so-called inherent factorsis, in absolute terms, higher than in thedeveloped countries, even though lessobvious proportionally. On the otherhand, many of these factors will be in-fluenced by improvement in environ-mental conditions resulting from the de-velopment of preventive programs. Atypical example is the effect of malnutri-tion in increasing prematurity and fetaldeaths and in decreasing average birthweights.

Contrary to the health problems inchildhood, specific problems of preg-nancy and childbirth are less directlydependent on safety of the generalenvironment. This is certainly relatedto the fact that women as adults havealready struggled through their bad en-vironment and obtained a measure ofadjustment. Programs aiming at theprevention of maternal mortality couldtherefore more easily be developed witha measure of success in technically lessdeveloped areas in the absence of greatimprovements in the general conditionsof living.The technically less developed areas

of the world suffer in the expansion oftheir health program from a series ofhandicaps common to all. These areessentially a severe shortage of health,medical care, and sanitary facilities, andof professional and auxiliary personnel,with an extreme maldistribution betweenthe urban and rural areas. Since the


lack of doctors and nurses is particu-larly serious for the maternal and childhealth program, an attempt is made todemonstrate this 6, 17 in Table 1.However, the table does not show theurban-rural maldistribution, nor does itgive an idea of the magnitude of theproblem in some areas, such as one doc-tor for approximately 70,000 populationin Indonesia, or one graduate nurse for46,000 population in Brazil. This situ-ation will make it necessary in mostcases to resort extensively to the servicesof auxiliary personnel, particularly inthe nursing field, and calls for attentionto the untrained village midwife whoseservices may be needed for many years.

Table 1-Estimated Population Per Doc-tor, Nurse, and Midwife in Areas of

World * Grouped According toInfant Mortality

Population perInfant Mortality

Doctor Nurse Midwife

Less than 50 per1,000 Live Births 900 500 1,940

50-99 per1,000 Live Births 1,600 2,600 4,400

100 + Over per1,000 Live Births 4,100 8,100 18,400

* Areas with data available for infant mortality andpersonnel

In the urban areas, with some in-crease in resources and improvement ofboth facilities and efficiency of person-nel, programs could rapidly develop onthe lines in which health services havedeveloped in the Western countries. Atthe rural local level, however, maternaland child health activities within thegeneral health program will at presentoften have to be carried out through ateam of workers with substandard levelsof training, such as a semiprofessionalnurse, an untrained village midwife, ateacher, a sanitarian, and with medicaladvice frequently available only on a

visiting basis and further limited helpfrom local community effort. Recog-nizing the limitations in personnel, ma-ternal and child health programs inthose areas should have well definedand limited objectives rather than try-ing to be all-embracing.The following are suggested as possi-

ble points of emphasis. For the ma-ternity care program there is firstneeded the extension of prenatal super-vision to the largest possible numberof pregnant women with increasein hospital facilities designed essen-tially for abnormalities of pregnancyand childbirth. Such a program in-cludes the use of the untrained villagemidwife for normal deliveries by givingher additional skills in hygiene andpromoting her supervision through thehealth center. According to the cir-cumstances, this program may be com-bined with an increase in normal deliv-eries in maternity centers. However,this part of the program should notreceive the major emphasis to the detri-ment of the other aspects.

For the infant and preschool ageprogram, points of emphasis will in-clude the acceptance of breast feedingas the surest life-saving device underpoor environmental circumstances, bothin terms of safe nutrition and the pre-vention of deaths from diarrheal disease.It is thus particularly important that, inour zeal to bring newer ideas of healthand hygiene, we do not break downexisting patterns of breast feeding. Thenutritional problems of the weaning andpostweaning period are most importantin the underdeveloped areas and there isgreat need for improvement of the nu-trition of the lactating mother in orderto help her feed her child more success-fully. Furthermore, early supplementaryfeeding with animal or vegetable pro-tein, according to what is available, isnecessary and often imperative, butshould be truly supplementary ratherthan attempting to replace breast feeding


at the young age of five to six months.The importance of diarrheal disease

in the technically less developed areasis evident from the observation that outof 18 countries of the Americas 18 re-porting rates in 1952, it was the leadingcause of death at all ages in eight andamong the first five causes in 12. Weknow that most of these deaths areof children under five years and it ap-pears that the larger portion of theseare due to specific infections, probablymostly shigellosis.

Recent evidence 19,20 indicates thatthe increase in readily available quan-tities of water is a more importantmeasure in preventing spread of diar-rheal disease than achievement of highstandards of water sanitation when onlylimited water is available. This knowl-edge will -obviously influence futurepolicies in rural areas. For those chil-dren who have acquired the disease themajor factor contributing to their deathis rapid dehydration. This knowledgeshould be imparted to all professionalworkers connected with the program.Teaching of simple methods of rehydra-tion, such as early ingestion of waterwith sugar and salt, or of a simple glu-cose and electrolyte mixture, which canbe recommended and applied withsafety by semiprofessional and auxiliarynurses, might in a program in ruralareas cut down the lethal effects of manycases of dysentery.

Although it might seem that healthservices for school children, in an ageperiod of relatively low mortality,would have a lower priority in the lessdeveloped countries, schools do offer anunequalled opportunity to reach fami-lies, as well as to attack specificallyprevailing diseases. Furthermore, theeducational program in schools will bethe avenue for betterment of under-standing for healthier living by futuregenerations.So far the discussion has been re-

stricted to the problems of survival and

physical illness. However, the mater-nal and child health program goes farbeyond this. It has taken a long timefor the technically developed countriesto realize the importance of a programaiming not only at survival and protec-tion from physical illness, but at thestimulation of harmonious growth anddevelopment of the child to adulthood.This concept broadens considerably theprogram and makes it touch on somephilosophical considerations with regardto the organization of communitiesupon which WHO's definition of healthis based. Since our present knowledgeof the psychological and emotional fac-tors related to growth and developmentstill needs much clarification it is nec-essary, in considering the situation ineconomically less developed areas, toproceed with caution. Indeed, all areashave definite patterns of child rearingand we should not apply too rigidly ourpresent thinking to pass judgment onthose that are very different.

Important drawbacks are frequentlyto be found, in terms of our presentknowledge on prevention of illness, inthe taboos associated with child rearingin many areas outside the Western cul-ture. On the other hand, in the sameareas good examples can be found offavorable circumstances associated withthe close relationship between the motherand her young child and within theexisting family pattern. Even if thereis a temptation to exaggerate the mentalhealth problems of the highly indus-trialized countries, because of the in-creasing emphasis they are receiving,there is evidence that the way in whichthe pattern of family life in the Westernculture has evolved in these rapidly ex-panding industrial areas is producinga number of problems which we nowhave to meet.The difference in the present patterns

of living may explain why women inthe underdeveloped countries, while defi-nitely in need of learning the principles


of hygiene and in need of advice tofree themselves from many taboos dan-gerous to the survival of their children,seem to have a greater capacity to ad-just, without stress, to their pregnancyand prospective childbirth. They alsoshow greater ease in establishing rapidlystable emotional relationships with theirnewborn infants, circumstances underwhich Western women seem, at present,to be more frequently in need of pro-fessional guidance and reassurance.Caution should therefore be exercisedin promoting the patterns of child-rear-ing of the Western culture which are infact continuously being reanalyzed bythe social scientist in terms of their im-pact on family and society.We seem to be quite sure of the ways

in which to improve the conditions ofphysical health of mothers and childrenin the economically less developed areas.The question of child-rearing practices,which is recognized to be the -fundamen-tal basis for future harmonious develop-ment of the individual, draws probablyequally good points in both the de-veloped and less developed areas.

Summary

Problems in maternal and child healthhave been contrasted in countries inwhich live only one-fifth of the worldpopulation with infant mortality of lessthan 50 deaths per 1,000 live births andthose countries in which three-fifths ofthe population live and have infantdeath rates exceeding 100 per 1,000.

Excessive mortality extends through-out childhood and is particularly evidentin the age group from one to four yearsin the economically less developed areas.It is chiefly due to gastrointestinal dis-ease, respiratory disease, infectious andparasitic disease, causes which arereadily preventable and have almostcompletely been eliminated in the de-veloped countries. Although not ap-parent in the statistical data, the influ-

ence of malnutrition on mortality isimportant.

Reduction of these preventable causesrequires both intensive expansion of thegeneral health program and develop-ment of specific maternal and childhealth activities. Services are particu-larly lacking in -rural areas in the lessdeveloped countries where the maternaland child health program can be de-veloped only slowly. It is thereforeproposed that under those conditions,rather than to attempt an all-embracingprogram, attention be given to specificpoints of emphasis, such as acceptanceof breast feeding as the surest life-saving device, stressing supplementaryfeeding of animal and vegetable protein,of the provision for readily availablewater to reduce the spread of diarrhealdiseases, and prevention of such deathsby early rehydration.The maternal and child health pro-

gram goes far beyond methods for pre-venting death and illness, in which thehighly developed countries are far ad-vanced, but aims simultaneously at thestimulation of harmonious growth anddevelopment of the child to adulthood.In this respect, the less developed areasdo not necessarily seem to be at adisadvantage.

REFERENCES1. Demographic Yearbook, New York: United Nations,

1952-1954.2. Statistical Yearbook, New York: United Nations,

1954.3. Annual Epidemiological and Vital Statistics. Geneva,

Switzerland: World Health Organization, 1952.4. Summary of Reports of the Member States, 1950-

1953. Washington, D. C.: Pan American SanitaryBureau, 1954.

5. De Haas, H. Data for the Netherlands on deathrates by age. Personal Communication.

6. Epidemiological and Vital Statistics Report, Vol. 7,No. 2. Geneva, Switzerland: World Health Organiza-tion, 1954.

7. Australia. Official Year Book of the Commonwealth,1927-1939.

8. Chile. Servicio Nacional de Estadistica y Censos.Demografia Aiio, 1952.

9. Columbia. Departmento Administrativo Nacional deEstadistica, Anuario General de Estadistica, 1951-1952, and earlier reports.

10. Mexico. Direcci6n General de Estadistica. AnuarioEstadistico de los Estados Unidos Mexicanos, 1953and earlier reports.

11. Sweden. Statistiska Centralbyran. Statistisk Arsbokfor Sverige, 1931-1939.


12. United States. National Office of Vital Statistics,Infant and Maternal Mortality Statistics. SpecialReports, Vol. 40, No. 13, 1952.

13. Posthuma, J. H. Perinatale Sterfte in Nederlanden andere landen 1926-1950. Tijdschrift voorSociale Geneeskunde 11-12 :273-292 (May 29), 1953.

14. Mauritius. Annual Report of the Registrar Gen-eral on Births, Deaths and Marriages, 1924-1953.

15. The State of Food and Agriculture. Washington,D. C.: Food and Agriculture Organization, 1955.

16. Troupin, J. L. Medical Schools and Physicians.Bull. WHO, Vol. 13, No. 2, 1955.

17. Statistics Relating to Medical and Para.MedicalPersonnel, Hospitals Facilities and Vaccinations

(Medical Statistics Documentation II D). Geneva,Switzerland: World Health Organization, 1954.

18. Molina, G., and Puffer, R. R. Report of HealthConditions in the Americas. Pub. Health Rep. 70,10-943-950 (Oct.), 1955.

19. Hollister, A. C.; Beck, M. D.; Gittelsohn, A. M.;and Hemphill, E. C. Influence of Water Availa-bility on Shigella Prevalence in Children of FarmLabor Families. A.J.P.H. 45:354-362 (Mar.), 1955.

20. Stewart, W. H.; McCabe, L. J.; Hemphill, E. C.;and DeCapito, T. L. The Relationship of CertainEnvironmental Factors to the Prevalence of ShigellaInfection. Am. J. Trop. Med. & Hyg. 4 :718-724,1955.

Public Health Business Management Seminars ScheduledA third seminar in Business Management in Public Health is announced for

January 23-27, 1956, by the University of Minnesota at its Center for ContinuationStudy, under the sponsorship of the Association of Business Management in PublicHealth. The basic principles of organizational and structural relationships, admin-istrative communications, financial resources, management methodology, andhuman relations will be presented through the group discussion method. Theseminar is designed to fit as closely as possible the expressed needs for knowledgeof special technics and procedures of the registrants themselves.

Panel participants include:Earl 0. Wright, chief, Division of Administration, Ohio State Department of HealthSam A. Kimble, chief, State Grants Services, Public Health ServiceOllie M. Goodloe, M.D., health commissioner, Columbus, OhioGeorge E. Williams, M.D., psychiatric consultant, Minnesota Department of Health

J. B. Yutzy of the Public Health Service, recently returned from a public healthadministration assignment in Liberia, will be general chairman. Application andfurther information from the Center for Continuation Study, University of Min-nesota, Minneapolis 14, Minn.

Documents

International Aspects of Maternal and Child Health: Variation in