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TWENTIETH MEETING

8-11 JUNE 1981

UKiUANIILA I urn WASHINGTON, D.C.

ADVISORY COMMITTEEON MEDICAL RESEARCH

REPORT TO THE DIRECTOR

REF: HRC/2010 JULY 1981

PAN AMERICAN HEALTH ORGANIZATIONPan American Sanitary Bureau, Regional Office of the

WORLD HEALTH ORGANIZATION K

Washington, D.C.

Pan American Health OrganizationOrganización Panamericana de la Salud

TWENTIETH MEETING OF THEADVISORY COMMITTEE ON MEDICAL RESEARCHVIGESIMA REUNION DELCOMITE ASESOR SOBRE INVESTIGACIONES MEDICAS

Washington, D.C.,8-11 June 1981

8-11 de junio de 1981

LIST OF PARTICIPANTSLISTA DE PARTICIPANTES

PAHO ADVISORY COMMITTEE ON MEDICAL RESEARCHCOMITE ASESOR SOBRE INVESTIGACIONES MEDICAS DE LA OPS

MembersMiembros

DR. GEORGE ALLEYNE*

DR. GUILLERMO ARBONA

DR. ROBIN BADGLEY

DR. CARLOS CELSO DEAMARAL E SILVA

DR. JOSE RODRIGUEZ COURA

DR. JOAQUIN CRAVIOTO

DR. JOHN R. EVANS

Professor of MedicineHead, Department of MedicineUniversity of the West IndiesMona, Kingston 7Jamaica

Profesor de Medicina Preventivay Salud Pública

Escuela de Salud PúblicaUniversidad de Puerto RicoCampus de Ciencias MédicasSan Juan, Puerto Rico

Professorc/o Committee of Sexual OffencesAgainst Children and Youths

Suite 150010 King Street EastToronto, Ontario M5C 1C3Canada

Companhia de Tecnologia de SaneamientoAmbiental

Rua Frederico Hermann Jr., 34505459 Sao Paulo, Brasil

Vice-Presidente de PesquisaFundacao Oswaldo CruzCaixa Postal 926, CEP 20000Rio de Janeiro, Brasil

Director CientíficoInstituto Nacional de Ciencias y

Tecnología de la Salud del Niño -DIFInsurgentes Sur No. 3700México 22, D.F., México

Chief, Department of Population,Nutrition and Health

World Bank1818 H. St.Washington, D.C. 20433

*ChairmanPresidente

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DR. CHARLES D. FLAGLE

DR. CARLOS LUIS GONZALEZ

DR. HERNANDO GROOT

DR. DAVID A. HAMBURG

DR. JESUS KUMATE

DR. CARLOS MONGE

DR. ALUIZ10 PRATA

DR. FREDERICK C. ROBBINS

Professor and HeadDivision of Operations ResearchDept. of Health Service AdministrationSchool of Hygiene and Public HealthThe Johns Hopkins University615 N. Wolfe St., R-7513Baltimore, Md. 21205

ProfesorDepartamento de Medicina Preventivay Social

Universidad de los AndesApartado postal 185Mérida, Venezuela

AsesorInstituto Nacional de SaludAv. El Dorado con Carrera 50Bogotá, Colombia

DirectorDivision of Health Policies Research

and EducationJohn F. Kennedy School of Government79 Baylston St.Cambridge, Mass. 02138

Jefe, Departamento de InmunoqufmicaDivisión de Investigación y EnseñanzaCentro Médico Nacional del IMSSAv. Cuauhtémoc 330México 7, D.F., México

Profesor de MedicinaUniversidad Peruana Cayetano HerediaApartado 5045Lima 100, Peri

ProfesorFaculdade de Ciencias da SaúdeUniversidade de BrasiliaBrasilia, Brasil

PresidentInstitute of MedicineNational Academy of Sciences2101 Constitution Ave., NWWashington, D.C. 20418

a

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DR. ANDRES O. M. STOPPANI

DR. LUIS VARGAS FERNANDEZ

DR. THOMAS H. WELLER

DR. RODRIGO ZELEDON

ProfesorFacultad de MedicinaUniversidad de Buenos Aires

Paraguay 2155Buenos Aires, Argentina

DecanoFacultad de Ciencias Biol6gicasUniversidad Catdlica de Chile

Santiago, Chile

Richard Pearson Strong Professor

of Tropical Public Health

Harvard UniversitySchool of Public Health665 Huntington AvenueBoston, Mass. 02115

DirectorConsejo Nacional de Ciencias y

Tecnología de Costa Rica

San José, Costa Rica

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WHO GLOBAL ADVISORY COMMITTEE ON MEDICAL RESEARCHCOMITE GLOBAL ASESOR SOBRE INVESTIGACIONES MEDICAS DE LA OMS

DR. SUNE BERGSTROM Chairman, WHO/ACMRDepartment of BiochemistryKarolinska InstitutetSalnavagen 1S-104-01 Stockholm 60Sweden

OBSERVERSOBSERVADORES

DR. CLAUDE LENFANT DirectorFogarty International CenterNational Institutes of HealthBethesda, Md. 20205

*

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PAN AMERICAN HEAITH ORGANIZATIONORGANIZACION PANAMERICANA DE LA SALUD

Office of the DirectorOficina del Director

DR. HECTOR R. ACUNA

DR. S. PAUL EHRLICH, JR.

DR. EUSEBIO DEL CID

DR. LUIS CARLOS OCHOA OCHIOA

DirectorWashington, D.C.

Deputy DirectorWashington, D.C.

Assistant Director

Washington,D.C.

Operations ManagerWashington,D.C.

Chiefs oí Division and Special ProgramsJefes de División y Programas Especiales

MR. FRANK A. BUTRICO

DR. MARIO V. FERNANDEZ

DR. JOSE R. FERREIRA

DR. SUMEDHA KHANNA

DR. JORGE LITVAK

Chief, Environmental Health ProtectionWashington, D.C.

Chief, Special Program for Animal Health

Washington, D.C.

Chief, Division of Human Resourcesand Research

Washington, D.C.

Chief, Division of Comprehensive HealthServices

Washington, D.C.

Chief, Disease Prevention and ControlWashington, D.C.

PAHO'S RegionalAsesores ReRionales

Advisors and Center Directorsy Directores de Centros de LA OPS

DR. HECTOR BOFFI-BOGGERO

DR. CARLOS DAZA

DR. JORGE CASTELLANOS

DR. JUAN CESAR GARCIA

DR. RAUL CASAS OLASCOAGA

ENG. JORGE ORTIZ

DR. RENATE PLAUT

DR. JAMES RUST

Regional Advisor in noncommunicablediseases

Nonconmmunicable diseases UnitDivision of Disease Prevention and

ControlWashington, D.C.

Regional Advisor in NutritionDivision of Comprehensive Health

ServicesWashington, D.C.

Regional Advisor in Medical CareDivision of Comprehensive Health

ServicesWashington, D.C.

Regional Advisor in SocioepidemiolocalResearch

Health Research Coordination UnitDivision of Human Resources and Research

Washington, D.C.

DirectorPan American Foot-and-Mouth Disease

Center - AFTOSACaixa Postal 589 - CEP 20000Rio de Janeiro, RKJ, Brasil

Regional Advisor in Operational ResearchHealth Research Coordination UnitDivision of Human Resources and ResearchWashington, D.C.

Regional Advisor in StatisticalMethodology

Health Research Coordination UnitDivision of Human Resources and ResearchWashington, D.C.

Regional Advisor on Enteric DiseasesCommunicable Diseases UnitDivision of Disease Prevention and

ControlWashington, D.C.

a

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DR. GABRIEL SCHMUÑIS

DR. ABRAAM SONIS

DR. ELBIO SUAREZ-OJEDA

DR. BRYCE WALTON

Regional Advisor in InstitutionalDevelopment

Health Research Coordination UnitDivision of Human Resources and ResearchWashington, D.C.

Director, Biblioteca Regional de Medi-cina y Ciencias de la Salud - BIREME

Caixa Postal 20831CEP 04023 Sao Paulo, SP, Brasil

Regional Advisor on Maternal and ChildCare

Division of Comprehensive HealthServices

Washington, D.C.

Regional Advisor in Biomedical Research

Health Research Coordination UnitDivision of Human Resources and ResearchWashington, D.C.

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WORLD HEALT1'H ORGANIZATIONORGANIZACION MUNDIAL DE LA SALUD

DR. MICHAEL MERSON Program Manager for Diarrheal DiseasesDiarrheal Diseases Control ProgramWorld Health OrganizationGeneva, Switzerland

REPRESENTl'ATVES OF OTHER REGIONAL OFFICESREPRESENTAN'[ES DE OTRAS OFICINAS REGIONALES

DR. B. AJAYAWEERA South East Asia Regional OfficeWorld Health OrganizationNew Delhi, India

SPECIAL GUESTSINVITADOS ESPECIALES

DR. ROBERT E. BLACK

DR. ADOLFO CHAVEZ

DR. YARO RIBEIRO GANDRA

DR. GUILLERMO LLANOS

Chief, Epidemiology SectionDivision of Infectious DiseasesSchool of MedicineUniversity of Maryland29 South Greene StreetBaltimore, Md. 21201

Jefe, División de NutricidnInstituto Nacional de NutriciónAv. San Fernando y Viaducto TlalpanMéxico 22, D.F., México

Catedrático de Nutrigao e HigieneAlimentar

Departamento de NutrigaoFaculdade de Saúde PúblicaCaixa postal 8099Sao Paulo, Brasil

ProfesorDepartamento de Medicina SocialDivisión de SaludUniversidad del ValleApartado 2188Cali, Colombia

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DR. FERNANDO MONCKEBERG B.

DR. JOSE OBDULIO MORA

Instituto de Nutricidn y Tecnologfade los Alimentos

Universidad de ChileCasilla 15138Santiago 11, Chile

Jefe del Programa de NutriciónFacultad de Estudios InterdisciplinariosUniversidad JaverianaCarrera 7 No. 40-62Bogotá, Colombia

TWJENTIETH MEETING OF THEPAHO ADVISORY COMMITTEE ON MEDICAL RESEARCH

Report to the Director1981

INAUGURAL SESSION

Dr. George Alleyne, Chairman of the Advisury Committee on Medical

Research (ACMR) opened the XX Annual Meeting of the Committee and

introduced Dr. Hector Acuña, Director of the Pan American Health

Organization.

The Director welcomed the members of the Committee and stressed

the particular importance of this year's meeting as the ACMR now had 20

years ot continuous existence. He also thanked all members for their

valuable assistance and advice regarding PAHO research activities and he

introducedc the new member ot the committee, Dr. Frederick Robbins and

also Dr. Claude Lentant who was attending the meeting as an observer.

Dr. Acuña stressed the importance of research in solving public

health problems and emphasized that health research in the Region should

be focused on problems which had a high social priority. He indicated

that the Organization was undertaking a wide range of actions in the

field oi research and was also strengthening research activities in the

Region by stitmulatiiig 'Techniczil Cooperation among the Countries to enable

theni to make full use ol their own resources.

He said that the PAHO Directing Council had approved the regional

strategies to meet the goal of "Health for All by the Year 2000". These

t.rl'ftegi s wete tl e terms ot reference for the present and future

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research activities of PA10. The present necessity was to define

priorities, promote regional programs, advise the Countries on developing

j research oriented toward solving priority problems and to achieve

scientific independence based on self-confidence and self-sufficiency.

Professor S. Bergstrom, Chairman of the global ACMR spoke briefly

and expressed his satisfaction at the important role that the PAHO ACMR

had had in PAHO activities through promoting and fostering research

within the Region.

Dr. Ferreira presented a report on the current situation of

Research in PAHO.

He indicated that five years had elapsed since the Division of

Human Resources and Research assumed the responsibility for promoting and

coordinating research in the technical cooperation programs of PAHO/WHO.

During these years, activities carried out were not only related to 'the

meetings of the ACMR, cataloguing of research projects, research and

research training grants, but also the programming was expanded to

include other areas as follows: a) promotion of national research

policies; b) establishment of priority areas in biomedical, socio-

epidemiological and operational research; c) development of an infor-

mation system on research in health; d) institutional development and

coordination of collaborating centers; e) technical cooperation for

training and advisory services in statistical methodology; f) coordi-

nation of the activities of the Special Program for Research and Training

in Tropical Diseases in the Region.

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To do so, it was necessary to increase the number of professionals

dedicated to the area of research from 2 to 5. At the same time, during

this period an overall increase in the research activities was observed

in the Organization. Both facts were reflected in the increase in the

budget of the research unit (from US$331,031 in 1976 to US$614,800 in

1981; 85% increase) and in the amount allocated to research programs in

the countries (from US$3,814,925 in 1976 to US$8,149,069 in 1981; 113% Lj

increase). This budgetary increase was more striking when compared with

the increase in the overall PAHO budget during the same period (from

US$63,352,642 in 1976 to US$92,117,450 in 1981; 45% increase).

The funds distributed by the TDR in Latin America and the

Caribbean area and the direct contribution of WHO to some of the

collaborating centers was US$5,400,000.

Since 1977, the PAHO research unit had promoted the definition of

National Research Policies in the countries of the Region. For this

purpose 10 national and five subregional meetings had been held. During

these meetings, the following themes were developed: a) structure and

organization of research; b) strategies of coordination and financing;

c) definition of priority areas; d) information systems on research; e)

training of researchers; f) the ethical aspects of research. The

results obtained so far had been very encouraging and indicated the need

to consolidate this work with a Pan American Conference on Research

Policies.

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Regarding research in priority areas several activities had been

undertaken. Six scientific meetings on health services research had been

convened with the participation of 200 specialists from different

countries. Furthermore, technical cooperation was provided to several

countries upon their request. Special emphasis was given to social

sciences through a study of social indicators in the region and a wide

review of the bibliography related to the subject and applicable to

health. Nutrition and Diarrheas were also other areas of concentration

ot activity.

PAHO maintained a grant's program which in the last five years had

supported 100 projects devoted to microbiology and parasitology, public

health and social medicine, internal medicine and its subspecialties,

biochemistry, physiology and other basic sciences.

PAHO research activities were also conducted in the ten PAHO

centers and in the WHO Collaborating Centers, which are national insti-

tutions, identified as Centers of excellence in specific areas.

In 1980-1981, 177 research projects were being conducted and/or

J supported by PAHO and the funds for these amounted to US$17,479,459.

Another activity developed during these years was a survey of

researchers, research institutions and ongoing research projects in

Central America, Mexico, Ecuador, and Bolivia. Outside the context of

PAHO projects, based on this survey, a directory of investigators in

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Latin America and the Caribbean would be made. Negotiations were being

conducted to expand the survey to other countries.

The role of BIREME in supporting the research effort in health in

the Region was noted. BIREME was not only the largest repository of

biomeaical information in Latin America but it was also the central

nucleus ot a network of scientific and technological information on

health. The publishing of the Index Medicus Latinoamericano was another

new inititive.

SESSION I

DIARRHEAL DISEASES

The Committee was informed about the WHO Global Program for

Control of Diarrheal Diseases, the PAHO/WHO Program for the Control of

Diarrheal Diseases (CDD), and the Progress on Research in Diarrheal

Diseases.

In May 1978, in response to a resolution adopted by the 31st World

Health Assembly, the WHO launched a Global Program for the Control of

Diarrheal Diseases (CDD). The diarrheal diseases had long been

recognized as a major public health problem in the developing countries,

and this initiative was in large part a result of the Organization's

commitment to primary health care and to the goal of Health for All by

the Year 2000. A further stimulus was provided by the significant recent

advances in knowledge about treament and prevention.

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The programs' immediate objective is a substantial reduction of

mortality trom acute diarrheal diseases and associated ill effects,

particularly malnutrition, in infants and young children; the longterm

objective is a reduction in morbidity from diarrhea.

The Programme haF two components; health services delivery and

research. In the services component, WHO activities have been directed

towards promoting and supporting the formulation of plans of operation

for national CDD programs, training and evaluation. To date, some 70

countries have taken steps to plan and develop national CDD programs as

an integral part of primary health care. The research component of the

program is designed to meet, and be responsive to, the needs of the

health service component, which in turn, provides a mechanism for the

early application of research findings.

In March 1980, following the recommendation of the Global Advisory

Comnlittee on Medical Research, a management plan for the research

component was implemented. This included the formation, at both the

global and regional levels, of scientific working groups (SWGs), composed

ot scientists from outside WHO, to plan and coordinate research

activities. The global SWGs are responsible for basic research

activities, while the regional SWGs, are responsible for operational

research. The three global SWGs met for the first time during 1980 and

developed a five-year research work plan and determined the priority

areas for research within the plan.

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The service and research components are integrated in one unified

management structure at the global, regional, and country levels. A

Global Technical Advisory Group (TAG), formed in 1978, has specific res-

ponsibility for reviewing and making recommendations on the direction of

the scientific and technical aspects of the services and research com-

ponents of the Program, including review of the program budget.

Commencing in 1981, the recommendations of the TAG are to be

turther considered by an annual Meeting of Interested Parties (MIP)

attended by representatives ot developing countries, governments and

agencies (including UN agencies), which are contributing, or are

interested in contributing, to the program. Prior to the MIP, the

overall management of the Program is to be reviewed by a Management

Review Committee (MRC).

In the period 1978-1981, the total funds received by the program

trom both regular and extradudgetary sources amounted to some 9.6 million

dollars. The projected estimated needs for the 1982-1983 are about 14.5

million dollars.

The terms of reference and the major regional activities of the

PAHO/WHO Program for the Control of Diarrheal Diseases (CDD), were des-

cribed. The four main strategies were outlined:

1) improvement of clinical management of diarrheal cases

utilizing oral rehydration therapy (ORT) and continued feeding;

2) institution of proper maternal and child care practices;

8-

3) provision of adequate water and basic sanitation facilities;

and

4) enhancement of epidemiological surveillance.

Although the ultimate control of infectious diarrheas may follow

substantial improvements in water supplies, sanitation, and education,

limited resources in many countries will prevent rapid changes in these

areas. However, recent research findings provide hope that the ill

effects ot diarrhea can be controlled now and that even the occurrence of

some important types of enteric illnesses may be prevented in the near

tuture. Significant advances have been made in three areas: 1) the

recognition of the role of the new viral and bacterial agents now makes

it possible to identify an etiological agent in most cases of acute

cliarrhea and to define the epidemiology of the enteropathogens; 2) the

demonstration that dehydration from watery diarrhea can be corrected and

prevented by the appropriate use of oral fluid replacement now makes it

feasible to prevent most diarrheal deaths; 3) the better documentation

ot the pathogenesis and immunology of enteric infections has enhanced the

development of effective vaccines to prevent diarrhea and typhoid fever.

The Committee discussed the progress made in this program at the

global and regional level. It was stressed that there was a considerable

heilth services research component to the program. Funds were being

spent tor training as this was important for the further progress of the

program. It was noted that there was no special component dedicated to

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the strengthening of institutions which could participate in the

program. This was in sharp contrast with the two other WHO special

programs, i.e. Tropical Diseases Research and Human Reproduction.

However, it was felt that the diarrheal diseases program was looking at

the effectiveness of institution strengthening in the other programs

betore becoming involved in this area. The point was made that in some

countries, institutional deficiencies were such as to impede progress in

all the programs and in such cases a joint approach to institution

strengthening would be desirable.

In the SEARO, a useful initiative had been the meeting of the

political decision makers and the active scientists. This had resulted

in wider acceptance of the program and more rapid implementation of some

of the established strategies.

There was regret that few institutions in the USA were working on

problems related to diarrheal diseases, and there was little support in

the USA for extramural projects in this area.

Some of the technical aspects of the program were also discussed.

There was debate as to the appropriate quantity of sodium to be used in

rehydration solutions for malnourished children who had abnormal

metabolic homeostasis. The general view was that the WHO formulation was

nmost appropriate for general use although there was a theoretical

possibility that it might not be ideal for the occasional child with a

complicated problem affecting water and electrolyte balance.

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SESSION II

HEALTH SERVICES RESEARCH (HSR)

1. Global HSR Program

The principal activity during the period was the VI Meeting of the

Global Subcommittee, which reviewed: a) general HSR concepts in support

ot the goal of "Health for All by the Year 2000"; b) specific aspects of

HSk in maternal and child care, and c) present and future activities of

the Subcommittee.

The countries had been increasingly accepting the importance of

HSR for policy-making and administration of primary care, but although

exchanges of information and experience with regional and national

representatives had created a climate favorable to such acceptance,

progress had been slow in the practical application of HSR principles and

purposes. There was agreement that HSR must include research on health

policies and on the structure, administration, organization and resources

of health services. The research must also focus on the analysis of

alternative solutions to the problems of delivery of services.

To foster effective application of those HSR principles, which

were important in terms of the global strategy for health for all, the VI

Meeting of the Subcommittee agreed on the following priorities: a)

promotion of political commitment to HSR, b) the organization and

mnanagement of health services, which is regarded as the most substantive

area ot HSR, c) conmunity participation, d) intersectoral action, and

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e) primary health care in urban areas. All these priorities related to

the real establishment of primary care as the principal strategy, and

would therefore apply directly to the situation in the Region of the

Americas.

The Subcommittee made several recommendations, as to the role of

WHO in ¡iSR:

- It recommended of WHO Secretariat be strengthened and that an

appropriate budget be allocated for priority areas.

- It also recommended that a scientific steering committee on HSR

be assernbled to continue the work begun by the Subcommittee, which would

be dissolved and that mechanisms for interagency coordination be

established.

- There was also the suggestion that a publication on HSR be

prepared and widely circulated.

The recognition of HSR as major instrument in the development of

health policies implies its incorporation into all service programs as a

basic component and the need to strengthen the country's capacity for

douiig so. This is thle area to which the technical cooperation efforts of

WHO and- PAHO must be preterentially directed.

2. Experiences on HSR in Colombia

This presentation was begun by referring to a study of human

resources for health and medical education carried out in Colombia,

between 1964 and 1968. Before this, the little research in this field

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had consisted ot isolated projects which had been undertaken on the

initiative of individuals, were generally descriptive and emphasized

purely pedagogical aspects of HSR. After this initial study, an adequate

structure was developed in the Ministry of Health and was consolidated by

the establishment in 1975 of the National Health System. The following

were given as examples of the kinds of HSR which had been initited more

recently:

- The Program on Research of Health Service Delivery Models

(PRIIMOPS) in the maternal and child health area, which is governed by

basic principles such as the epidemiological approach for the

identification of groups at risks, the organizing of services by level

oi complexity, the development of personnel training programs in

accordance to the task to be performed by each member of the health team,

community participation, and the ongoing evaluation of actions.

- The Program of Research in Simplified Surgery (SIGSIM), which

is the model for the extension of coverage for surgical problems. There

are similar models for the areas of Psychiatry and internal medicine.

- A Center for Multidisciplinary Research in Rural Development

(CIMI)ER), which operates essentially in the rural area with the view to

the developnent oi appropriate technologies for comprehensive primary

care.

- The Program of Research and Development of Health Systems

(PkIDES), which centers on the evaluation of the management of health

service delivery institutions.

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- The National Inventory of Health Resources and Research (INRIS)

established by the Research Department of the Ministry of Health, which

has identified the current studies on the subject in the country.

Health Services Research had evolved to the stage where it was now

multidisciplinary, multi- institutional, and analytical, with more empha-

sis on service and on integration of service and education.

The Committee discussed the presentations on HSR. It was agreed

that if HSR were not action oriented it wuld run the risk of becoming a

purely theoretical discipline which would not attract support. It was

also essential that personnel should be trained locally as far as

possible. Prospective studies should be promoted as they were likely to

be less controversial, more acceptable and more useful.

The Committee considered the need to focus on the problem of

litiancing ot the health sector and the decision-making processes which

altected such financing.

With respect to the role HSR should play in the health service

systems, the Committee agreed that HSR should be regarded as a horizontal

or transdisciplinary component of health systems and not as an isolated

entity. HSR should play a role in many of the current programs at the

Regional and Global levels, eg. the diarrheal diseases program and the

program on nutrition and malaria. the Committee accepted that, although

}iSK was transdisciplinary, technical competence was essential in those

tieLds embraced by HSR, eg. clinical epidemiology, biostatistics,

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demography, the social and behavioral sciences and economics. This

implied that there should be strategic location of training centers of

quality in those critical fields if HSR was going to be effective in the

Region.

3. Report of the Workshop on Implementation of HSR Research

This workshop had been multidisciplinary and had considered

recommendations for promoting and allocating the capabilities of the

countries for the development of HSR. A scheme for the assessment of an

integrated service and education research program was also reviewed.

The recommendations for implementing a HSR program were made

following identification of the main difficulties for its development.

The need for improvement in the following areas was indicated: 1) the

training ot human resources, both of researchers and users, 2) the

creation of conditions favorable to the development of HSR, and 3) the

use and application of HSR in services.

The workshop recommended the establishment of offices for the

ptIttiofl ol HSR in the countries, the development of action-oriented

re search, the involvement of users in the research process, the

Ldentitication of centers with experience in HSR which could be used to

promote the development ot HSR and to train personnel.

With regard to the assessment of an integrated service and

education program, the workshop defined the components of the program in

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terms ot systems (health services, teaching services, research,

political-administration levels, and the community), and proposed

objectives for each of them, as well as how they were to be

interrelated. Two possible evaluation methods were recommended: the

analysis of temporal trends (before and after), and the use of

experimental and control groups.

The Committee discussed the recommendation made in the Workshop

that an institutional network, based on existing centers, be set up for

manpower training in operations research. The possible catalystic role

of PAHO in implementing this recommendation was stressed.

The discussion also brought out the need for effective coordina-

tion between the university and the health delivery systems and

reiterated the need tor highly qualified manpower which would seek to

adapt and not to adopt systems.

The suggestion was made that studies should be carried out on the

niechanisms whereby health services were financed in different countries.

Such studies might include analysis of the expenditure as channelled

through different sectors such as private health care, social security

systems, ministries of health and others.

4. HIealth Services Research as a Component of Health Research Devel-

opnient

In the presentation of this topic it was reiterated that the

purpose of Health Services Research was to provide knowledge to guide the

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development of health services in the achievement of their objectives.

It was characteristic of all developing human organizations that there

must be interacting components of teaching and research supporting the

services with new personnel and new knowledge.

There were several ways in which research fulfilled this

function. First it played a part in evaluation of alternative modalities

and strategies of service. It provided the tools to measure the

characteristics of utilization of services as well as their effectiveness

and cost. Also systems research provided the discipline for examining

not only the internal working of a health service, but also its

interaction with the larger systems of which it was a part.

The ACMR had a unique opportunity to aid the development of health

services, since its membership represented many disciplines in biomedical

and health services research. It was felt that one approach to improving

health services research could be the identification of research groups

in this area in various countries of the Region, and the establishment of

a network mechanism for fostering collaboration among them and

potentiating their development efforts.

5. Social Science Health Research

Ihe Working Group, which had been established as a result of

reconimendations of the 19th PAHO/ACMR Meeting, reported on steps taken to

fultill its mandate. The social sciences health research inventory had

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been augmented by additional references and would be submitted to BIREME

tor consideration and review as a special purpose bibliography. Steps

had also been initiated to compile an annotated bibliography of major

studies involving social science research related to the distribution and

control of malaria.

In connection with the request to identify the potential input of

the social sciences related to a disease assigned high priority by the

Organization, an interdisciplinary and interagency group started its

consideration of (1) the social and economic factors known to affect the

transmission and the distribution of malaria; (2) the acceptability and

effectiveness of control measures; (3) the organizational aspects of

antimalarial programs. Ihe group initiated: (1) a review of related

prior work in this field by committees of the Organization; and (2) the

identitication ot relevant research dealing with these issues. The

principal purposes of this review were: (1) to identify the social and

economic variables correlated with to the occurrence and control of

malaria; (2) to develop ways of strengthening interdisciplinary

collaborative research; (3) to consider needs related to training and

resources; and (4) to foster the coordination between existing programs.

As part ot its work the interdisciplinary group visited the malaria

programs in Tapachula, Mexico; Nicaragua and the Dominican Republic.

In addition to starting to develop a conceptual and research

traniework lor the study of the social and economic aspect of malaria

- 18 -

which could be the basis for other diseases, the Working Group proposed a

number of general principles for the conduct of such studies. These

principles were: (1) the full review of relevant completed and ongoing

research; (2) the establishment of a data bank of social and economic

variables permitting the analysis of different diseases; (3) the

concentration on social and economic factors generic to a number of

deseases and common to several nations, e.g., the effects of migration,

the dynamiic of public participation in control programs, (4) the

establishment of an integrated approach -between agencies, nations and

disciplines. It was emphasized that the initial approach should be

action-oriented and that local resources should be strengthened, where

required, by providing training opportunities and external expert

consultants.

As its identification and development of a conceptual and research

framework of relevant social and economic variables related to malaria

and other diseases was incomplete, the Working Group was of the view that

an examination of the application of the social sciences in health be

continued, and specifically, in the social and economic aspects of mala-

ria.

The Committee received the report and in the discussion it was

noted that much relevant research experience completed in the past was

not well known. Although the relevance of social and economic variables

was accepted in the operations of antimalarial programs there was still a

- 19 -

wide variation of opinion as to what role the social sciences might play

in health related research in general. The interdisciplinary model being

developed for malaria would be extended to other disease conditions and

the principle would be accepted that research excellence and training in

this field and for health services research should be fostered in a

network of nationally based centers.

With regard to the awareness of personnel of the role played by

the social science in the study and solution of the problems caused by

malaria, the situation varied from country to country. There was

opposition in some and unreserved support in others. In places like

Chiapas there was a widespread conviction of the key role that migration

played in the maintenance of malaria transmíssion. In Nicaragua, too, it

was accepted that social and economic factors influenced health problems.

The Committee was reminded of the social orientation of many

research projects in the ecology and epidemiology of malaria conducted

prior to 1945 under the auspices of the Rockefeller Foundation. It was

enmphasized that the work done by the Subcommittee on the malaria

situation in the countries which had been visited could be regarded as a

study whose findings could be applied to other problems.

The Committee accepted the value of the work done by the

Subcommittee, and it was felt that as a general principle, subcommittees

ot the ACMR should be advisory and formulate recommendations and not

enter the operational area.

- 20 -

SESSION III

NUTRITION

For this session there were presentations of the experience from

four different countries of the Region as well as the work attempted at a

global and regional lev'l. These experiences were used to formulate an

approach to a regional plan for nutrition research.

1. Mexico

Mexico had been experiencing a major social change, particularly

in its rural-urban balance and its production patterns. A very rapid

transition trom subsistence to commercial agriculture had caused a

significant lack of basic products and substantial changes in consumption

patterns. The Government had responded by establishing the Mexican Food

System (SAM) to promote self-sufficiency in food and improve food

distribution throughout the society.

The information needed for programming the SAM had been supplied

particularly through three applied research programs: one in food

technology tor social welfare, another in nutritional epidemiology, and a

third for the experimental development of problem-solving methods.

Ihiese investigations, joined to other less direct practical

research, constituted an infrastructure of knowledge that was fairly

advanced for an underdeveloped country, but still insufficient for one

that wanted to solve its nutritional problem. Hence, specific research

- 21 -

must be planned for the long term in the light of resources and needs,

and in the short run technological development should be sought for the

application of detection-care packages in nutrition and primary health.

2. Brazil

Ihe nutritional problems of Brazil were for the most part a

consequence of the country's socioeconomic problems. In addition, there

was the problem of irregular distribution of the population. This varied

by a factor of 15 through various parts of the country. It was therefore

ditticult to implement or coordinate any programs at a central level.

The irregular distribution of population did not only mean difficulty in

execution of programs, it also meant that different groups had different

eating patterns with marked variability in terms of consumption of

calories and other nutrients. In certain parts of the country food

consumption depended very much on agricultural production which in turn

was related to such things as the history o# farming, the economic

pressure on the land owners and the priorities given to agriculture

itself irn the whole national economic policy. The country counted on the

national program of food and nutrition which was an interministerial

program coordinated by the National Institute of Food and Nutrition.

The major nutritional deficiency in Brazil was protein-energy

malnutrition among infants which in fact was mainly a deficiency of

energy rather than protein in the lower socioeconomic groups of the

- 22 -

population. Another interesting aspect of the problem of childhood

nutrition was the straight line relationship between low birth weight and

death in the first month of life. The incidence of low birth weight was

as high as 15% in some parts of the country. The problem of infantile

malnutrition was being tackled by the development of multisectoral

projects. The role of early cessation of breastfeeding as a cause of

malnutrition was also discussed. Nutritional anaemias, xerophthalmia,

endemic goitre and dental caries were some of the other significant

nutritional problems which existed in Brazil.

The state of nutrition research in Brazil was also presented.

Although over the past 20 or 30 years studies in nutrition had extended

trom the basic physiology and clinical nutrition to include studies on

dietary food habits and the relationship of dietary deficiencies to the

ecosystem, there was little evidence that any of these studies had had

rmuch effect on the official nutrition programs. There was recent

evidence however that research into the social aspects of nutrition was

growing and having some impact. It was also of relevance that teaching

oi nutrition in medical schools had increased and the number of schools

of nutrition had grown.

It was felt in general that action oriented programs of nutrition

research could have a role in primary health care. There were

ditficulties in selecting appropriate groups for attention but it was

probably most useful to select families at the lower socioeconomic levels

- 23 -

for the major inputs. One point which was stressed was that there had to

be integrtion between the universities and the ministries in executing

any program for investigation.

3. Chile

During the past twenty years there had been continuous improvement

in the health conditions in general and the nutritional status in

particular of Chile's infant population. Health indicators such as

infant mortality, deaths from diarrhea, prevalence of infant malnutri-

tion, all confirmed this trend of improvement. There was general agree-

ment that infant malnutrition results from socioeconomic deprivation but

it was striking that the improvement in the nutritional status of

children in Chile had taken place in the absence of any parallel socio-

economic development.

The causes of this apparently anomalous change in nutritional

status were analyzed. The first important factor was the development of

health and education systems which had steadily expanded their coverage

and improved their efficiency. The other factor was the development of

appropriate nutrition research.

Although there was proper emphasis on prevention, the health

systems had developed certain nutrition intervention programs which

included such things as distribution of appropriate food and the

establishment of recovery programs for those children who did have

- 24 -

clinical stigmata of severe malnutrition. Nutrition research had been

developed primarily at the university centers but the results of much of

this research had been widely disseminated through the country. An

interesting aspect of nutrition research in Chile was that it had

steadily become more applied or operational.

The structure of nutrition research in Chile was described with

particular emphasis on the programs of the Institute of Nutrition and

Food Technology. This institute appeared to have a wide base and a

multidisciplinary focus covering at least five aspects of nutrition and

food science.

The apparent success of Chile in the area of nutrition was seen to

be the result of several factors. These included food research of local

relevance, the creation of political consciousness as to the value of

work on nutrition and the appreciation that the primary care system was

the vehicle for affecting much of the desired change.

4. Colombia

Ihe report listed briefly the most outstanding nutritional

problems of the Colombian population, which apparently had persisted

without notable modifications through the last twenty years. It showed

the principal fields in which nutritional research was currently being

done in Colombia, indicating some examples of specific projects. The

majority of the research was of a diagnostic type (clinical and

- 25 -

epidemiological), but prospective studies of the experimental type and

specific projects of action-oriented research on nutrition were also

being carried out.

The opportunities and needs of action-oriented research as a

component of primary health care were multiple, and extension of coverage

constitute the fundamental objective of the strategies of the current

National Health Plan of Colombia. The promotion and intensification of

action-oriented research towards the search for methodologies and

appropriate technologies were considered necessary, and these would

optimize the efficiency of the activities in nutritional education,

nutritional surveillance, promotion of breastfeeding, improvement of

infant-feeding, dietetic management of diarrheas and infections,

community organization, and other things which constitute the nutrition

component of primary health care.

5. PAHO Regional Program on Action-oriented Research in Nutrition

The results of the PAHO/WHO Technical Working Group Meeting on

Nutrition, held in Bogota, Colombia, from 16 to 20 June 1980 were

summarized. There were also comments on the preliminary report on

potential resources for the development of action-oriented research on

nutrition in Latin Anierica, as a result of visits made by a PAHO

Consultant to the following countries: Argentina, Chile, Colombia, Costa

Rica, Guatemala, México, Peri and Venezuela, from 15 February to 14 March

1981.

- 26 -

Proposals for action-oriented research at the regional level as

well as strategies for the programs' execution should result in the

following:

1. Preparation of an inventory on human and institutional

research on nutrition and health, social sciences and community

development.

2. Identification of national programs on primary health care,

where action-oriented nutrition research activities may be included.

3. Promotion of an active interaction between scientists on

nutrition, health, social sciences, economics and other disciplines

related to food and nutrition problems. This would be achieved by

designing and developing specific projects in which researchers and

health administrators could participate.

4. Provision of financial and technical support to strengthen

those national institutions which can offer opportunities for training in

basic, applied and operational nutritional research.

5. Procurement of regular financing for the development of

action-oriented research projects in nutrition through services in

primary health care, according to principles and guidelines recommended

by the Technical Group on this subject.

6. Creation of a Group for the Revision of Projects, which,

besides reviewing the scientific quality of the research proposals, would

support in a direct way new researchers who wished to design and develop

- 27 -

projects in their own countries. Attention would be paid to the

strengthening of existing institutions capable of training national

professionals in research.

The above mentioned actions would be seen in the light of the

technical cooperation between countries aimed toward the development of

their Gwn scientific and nutrition research capability.

The Committee discussed the presentations.

Considerable attention was focussed on the fact that the success

in Chile had been achieved even though there had not been concomitant

improvement in the critical social and economic variables in that

country. It was impressive also that the achievements in this field were

not at the expense of other social services. The Chilean experience

showed that it was important to look at all the social programs bearing

on the child as a whole.

The experience of all the countries was that resulte were achieved

only after there was a commitment by policy-makers to implement the

program and see that it continued.

Reference was made to the initiatives being taken at the global

level in nutrition and the difficulties which had been encountered. In

this context, the progress being made in the PAHO Region was most

encouraging. It was felt that a rationale for PAHO continuing efforts in

the field of nutrition related research would be the fact that already in

- 28 -

the Region there were strong programs which could be models for the rest

of the world. There was also a receptive scientific community which was

showing evidence of a multidisciplinary orientation to these problems.

Nutrition provided an opportunity to link biomedical research, health

services research and the behavioral sciences. It was also pointed out

that the Region was uniquely fortunate in the wide diversity of

ecological and social circumstances which enhanced the value of

comparative research.

It was suggested that the major thrust of nutrition research

should be towards the most vulnerable groups, i.e., young children,

pregnant mothers and perhaps adolescents. The suggestion also was made

that the nutrition package in primary health care was :the approach which

might be most effective in solving the nutrition problems of vulnerable

groups. However, it was pointed out that no single approach was likely

to be completely etfective. Stress had to be placed in the community and

its participation as being essential for the success of any program of

this type. In considering the nutrition problems of a country, care had

to be taken to evaluate the problems not only of under-nutrition, but of

malnutrition leading to obesity and other ills.

The Committee agreed to establish a small ad hoc subcommittee to

collate the important aspects of the presentations and discussions and

present a plan of action at the executive session.

- 29 -

SESSION IV

OTHER TOPICS

1. Mental Health

There was a report on a new WHO initiative in research on mental

health and biobehavioral sciences. A new subcommittee of the global ACMR

was initiated at its 1979 meeting and approved by the Director-General.

This subcommittee would address mental health problems, broadly

conceived. The problems of mental health and, more broadly, the

behavioral factors in health generally, had recently become matters of

some concern.

A behavioral science area of worldwide concern, emphasized by the

ACMR in 1979, was research on health education. Health education was of

crucial importance --both for more and less developed countries-- for

wise use oí the health care system, and for minimizing lifestyles that

were damaging to health. Research could be helpful in clarifying the

most effective methods for attaining those goals.

There was an urgent need for research on the great problems of

developing countries in the sphere of behavior and health. While this

need included the established mental health problems, these must be

viewed in a broad context of behavioral factors relevant to health

--e.g., in the context of nutrition, sanitation, family planning,

migration, alcohol, smoking or whatever behavioral factors have a

potentially strong bearing on the protection of health.

- 30 -

Striking advances within the neurosciences and promising progress

within the behavioral sciences had begun to provide a critically

important set ot tools for approaching major problems in health.

Primary health care was widely viewed as the most cost-effective

approach to improving health in developing countries. It was central to

the goal of "Health for All by the Year 2000". Although the Alma-Ata

detinition ot primary care was very broad, it included these elements:

1) prenatal, obstetrical, and post-partum care; 2) family planning

services; 3) immunization for childhood diseases; 4) basic medicines

such as oral rehydration; 5) first aid; 6) health education on such

matters as nutrition, oral rehydration, and sanitation. All of these

involve important aspects of human behavior which were increasingly

amendable to scientific study.

Primary Health Care should include a mental health component,

dealing with common disorders, such as schizophrenia, depression, and

epilepsy. Primary care involved community health workers supported by

trained nurses and physicians. Mental health workers should be a part of

the primary care team. Studies were needed of different ways in which

the mental health component might be effectively integrated into whatever

general health services were available.

A WHO group had recently reported on a collaborative study

undertaken in seven developing countries to investigate the extent of

mental health problems, community response to mental disorders, and the

- 31 -

possibility of providing basic mental health care as part of primary

health care. The experience obtained had shown that existing health

staff were capable of acquiring mental health skills and appying them to

provide basic mental health care and the additional resources required

for this purpose were modest. The testing of these accomplishments on a

wider scale was now appropriate.

The following priorities had emerged from the subcommittee

deliberations:

1. Ongoing WHO research in mental health in developing

countries should address first those aspects of mental health which might

be implemented practically in primary health care.

2. Among the primary areas for technical and financial

assistance, and for global and regional cooperation, highest priority

should be given to institution strengthening for the purpose of ensuring

long-term commitment and continuity in research, development and training

in mental health. The support for institution strengthening should be

concentrated initially on a small number of centers with exceptionally

high potentiality.

3. WHiO should stimulate through its various programs efforts of

member states to conduct research on health education pertinent to major

burdens ot illness in developing countries.

The report of this subcommittee was well received by the global

ACMR, which in turn recommended to the Director-General that a scientific

- 32 -

steering committee be established to foster research on these problems.

He has approved and the work is beginning to go forward. The PAHO Region

should play a major role in this effort.

2. Activities of the Foot-and-Mouth Disease Center (AFTOSA)

The Committee received a presentation on the activities of the Pan

Amnerican-Food-and-Mouth Disease Center. This center's research program

was oriented towards solving the problems which arose during execution of

the programs to prevent, control and eradicate foot and mouth disease

(FMD) in the Americas. The Center's research program could be devided

into 13 different but interrelated projects.

1. Diagnosis of vesicular disease of livestock. This covers the

identification and classification of agents causing vesicular

disease in animals and provision of reference biological

materials.

2. Selection of FMD vaccine strains -selecting for vaccine

production those virus strains which have good immunological

relationships to strains which are causing disease in the

field.

3. FMD vaccine antigen production. This involves determining the

optimum conditions for antigen production and also work on

antigen purification concentration and stabilization.

- 33 -

4. FMD vaccine adjuvants. This deals with the development of a

high potency vaccine for cattle and pigs.

5. Field application of oil-adjuvanted vaccines. More than half

a million cattle have already been included in field trials

with vaccine produced by the center.

6. Attenuated live virus vaccines. This project is being phased

out in view of the very successful development of immunogenic

oil-adjuvanted vaccines.

7. Quality control of FMD vaccine. The center acts as a

reference center for the Americas for vaccine quality control.

8. Pathogenesis, transmission and revision of FMD virus.

9. lmprovement of laboratory techniques for FMD research.

10. FMD epidemiology.

11. Operational analysis of FMD control measures. This includes

studies on the costs of vaccination and evaluation of

alternatives to vaccination.

12. Models of FMD epidemiological processes.

13. Studies on the production and yield losses in FMD affected

cattle.

The Committee discussed the work of the Center and there was

strong commendation for the research program which was being undertaken.

The Committee discussed the problems which attended serious attempts to

eliminate the disease from the Hemisphere, and it was felt that the work

of the Center was critical to any such elimination program.

- 34 -

There was also discussion on the budgetary problems which the

Center was encountering. Dr. Acufla described some of the difficulties

which the Center had been experiencing especially since this disease was

sometimes seen as not really being a zoonosis. He suggested that some

members ot the ACMR might be invited to attend the next scientific

advisor; committee meeting of the Center so that the ACMR might be better

appraised of the research and other problems which the Center faced.

3. The Risk Approach in Perinatal and Maternal and Child Care

The Committee received a presentation on this topic in which it

was pointed out that an essential part of the studies on risk approach at

least in maternal and child care was to define carefully the

characteristics of the individuals and groups "at risk". The "risk

approach" should be seen as a management strategy for a better design of

the services.

WHO was engaged in an interregional project, which PAHO had

joined, which was promoting research and the applications based on this

zappro¿acl. A guide to the execution of these projects had been prepared

with the sequence of steps clearly spelled out.

The lst Regional Meeting on the "Risk Approach" was held in March

1981; it considered the experiments now in progress in the Americas and

made recommendations for their continuation. Of particular interest were

the experiences ot Colombia, Cuba, Peru and Brazil in using the risk

approach as an instrument in the delivery of services.

- 35 -

Risk factors varied from one country to another, and national

local epidemiological studies were needed instead of directly applying

the predictive models of other countries. The number of variables

studied at the outset may be large. However, it would be necessary to

select the most important ones to arrive at relevant "predictive modelsg

which could be adapted to the capabilities of the personnel in charge of

applying the model. The "risk" methodology was becoming a bridge between

clinical epidemiology and the administration of health services.

The Committee discussed this presentation and it was pointed that

the risk approach was a methodological tool not only of value for

maternal and child health, but aleo for the expansion of primary care

services. This approach was relatively recent but had already stimulated

several prospective studies which had already generated predictive

models. However, further research was necessary to improve the

predictive power of the existing models. Ic was clear that there were

enough local regional differences in population characteristics to make

it mandatory tor researchers to-develop locally relevant models.

4. PARO collaborative study on rheumatic fever

The results of a PAHO collaboyative etudy on rheumatic fever were

presented.

The efficacy of penicillin prophylaxis against rheumatic fever has

been well established but rheumatic fever and its signelae continued to be

- 36 -

a major health problem in the developing countries. the Pan American

Health Organization therefore initiated a collaborative study to some

countries in Latin America to examine the feasibility of carrying out a

control program and as concomitantly to give some service to the

communities under study. It was a 5-year study which was completed in

1980. A preliminary analysis of the data showed that the evidence of

respiratory streptococcal infections did decrease with successful

penicillin prophylaxis. It is hoped that further analysis of the data

will show the feasibility of incorporating such a control program into

the countries' primary health services.

The Committee discussed this study and although there were

problems with verification of the authenticity of some of the individual

data points, it was agreed that this should not detract from the effort

in stimulating interest in a control program for rheumatic fever. The

study had raised several questions which might be the subject of further

research.

EXECUTIVE SESSION

1. 23rd Meeting of the Global ACMR

The Committee received a report by Dr. S. Bergstrom, Chairman of

the Global ACMR on the 23nd meeting of that Committee. There were to be

changes in the composition of the Global ACMR in that no country would

- 37 -

have more than one representative. The reports of the Special Programs

had been considered and with respect to the Human Reproduction Program it

was stressed that there was an urgent need to look more closely into the

psychosocial aspects ot tertility control and also to continue to pay

attention to improvement in contraceptive technology. As far as the

Tropical Diseases Research Program was concerned, a major development had

been the decision ot the World Bank t so pport the program financially.

Note was taken of the custom of having the Chairman of the Global

ACUiR report directly to the Executive Board and to the Assembly. This

practice was also being followed in the various regions. With regard to

nutrition, the Global ACMR was concerned at the lack of progress in this

area. It appeared that attention might be given to condensed programs

relating to maternal and child health. Such programs might embrace

diarrheal diseases as well as nutrition. In the discussions at the

Global level, the regional initiatives in health services research were

commended.

At-er discussion on this report the Committee agreed that if more

eltort were tocussed on maternal and child health problems, this might

accelerate progress towards achieving Health for All. It might be

possible in a single discrete area to measure progress and evaluate the

success ot specific, interventions. It was also pointed out that the lack

ot proper information and failure of dissemination of this information

were obstacles to achieving Health for All and these two areas should be

- 38 -

tackled vigorously.. The health services research committee of the Global

ACMR was being dissolved as a part of the phi'losophy that subcommittees

were advisory and should not be involved in the operations aspects of

health.

Dr. Bergstrom mad3 a plea for sensitizing Ministers of Health to

the necessity for speaking in the appropriate fora about the potential

and real advantages of the special programs which were being funded by

extrabudgetary funds.

2. Recommendations of the l9th Meeting of the PAHO/ACMR

The Committee reviewed the recommendations which had been made at

the previous meeting, specifically to determine what progress had been

made and whether new initiatives had become necessary.

2.1 Diarrheal Diseases

The Committee took note of the presentations which had been made

at this meeting and the discussion which had resulted. The Committee

noted with pleasure that the subcommittee on Diarrheal diseases had been

subsumed under the new scientific working group on diarrheal diseases.

The coniposition of this working group also reflected the wish of the ACMR

to see inclusion of "social and operational research capabilities".

The Committee recommended that

a) A progress report of the activities of this SWG be

presented at the next meeting of the ACMR.

- 39 -

b) The results of the forthcoming meeting of the SWG be

circulated to all ACMR members.

c) A strong emphasis should be placed on operational and HSR

aspects in the program as a whole and in any projects

which were being planned or funded.

d) Eftorts should be made to increase the number of

epidemiologists in the area and to foster the training of

scientists concerned with the problem.

2.2 Health Services Research

There was extensive discussion on the role and image of health

services research. It was postulated that a proper approach to health

services research might be to see its usefulness as one tool for the

solution of problems. Perhaps an appropriate approach might be to focus

first on the problem to be solved and then secondarily on the use of

health service research to determine which of its component disciplines

was most useful for the solution of the problem. In this sense, this

emphasis should not be placed on the pursuit of health services research

as a "tree sLanding" discipline. However, attempts should be made to

develop an appropriate milieu in which health services research could be

operational, especially as a component of primary health care.

The Committee agreed to recommend that

a) There should be a change in focus vis a vis HSR. PAHO

should try to select a few categorical programs and

- 40 -

introduce HSR into these programs in an evaluative or

operational mode instead of insisting on the formulation

of a vertical HSR program.

b) Efforts should be made to attract some of the academic

community into health oriented research activities and

focal poínts should be identified to promote harmony in

HSR capabilities.

c) The present subcommittee on HSR should cease to function

but the topic of HSR should be constantly before the ACMR.

2.3 Social Sciences related to HSR

The Committee discussed continuing activity in this area. There

was discussion as to what was the appropriate focus for the social

science disciplines especially in relation to HSR. It was conceivable

that the focus should be on strengthening the discipline of social

science per se, or perhaps aggregating several apparently disparate

disciplines under the umbrella of health sciences research. The view was

expressed that further work was necessary in formulating a conceptual and

research framework within which the social sciences could contribute

etfectively to health care. It was felt that the work of this sub-

committee was still incomplete but in its future functioning it should be

catalytic rather than operational.

The Committee agreed to recommend that

a) The scientific subcommittee should continue its activities

and complete its work in one year.

- 41 -

b) The Subcommittee should:

i) Complete its work on the development of the

inventory on social science health research, and

specifically, related to social and economic

research on malaria.

ii) Continue to develop the conceptual and research

framework for the research by the social sciences in

relation to malaria.

iii) Examine the state of field work and epidemiological

research being done on malaria.

2.4 PAHO guidelines and review procedures for the protection of human

subjects in medical research

The Committee discussed the implementation of the recommendations

made at the l9th meeting. The recommendation that an external review

committee be formed posed administrative and logistic difficulties. The

ACMR restated its concern over the importance aof this matter as failure

to have proper ethical review procedures for human experimentation might

retlect adversely on PAHO. It was also pointed out that WHO and CIOMS

had recently prepared a major document on ethical review procedures.

The Committee recommended that

a) The ACMR members be circulated with the full documentation

of the procedures used by the PAHO review committee.

- 42 -

b) This item be kept on the agenda and be discussed at the

next meeting by which time the final report of the

WHO/CIOMS group would be available for study and

discussion.

2.5 Regional activitics vis-a-vis the Special Program for Research and

Taining in Tropical diseases

The Committee heard that it had been felt inappropriate to

establish a regional counterpart with TDR. However, it was felt that the

activities related with TDR programs were not sufficiently publicised and

actively promoted in the Region. Several of the countries which had the

problems of the six diseases were not being involved in the activities of

the Special Program.

The Committee considered the TDR program to be specially important

and teld that it could plan an even greater role if provided with

additional resources. Every effort should be made to enlist more

voluntary contributions from the countries of the region to this as well

as the new diarrheal disease program.

The Committee recommended that

a) Efforts should be made through PAHO to stimulate interest

and promote participation in the TDR program.

b) Members of the Committee should be circulated with the TDR

regional profile.

- 43 -

c) A report on the TDR should be presented at the next

meeting of the ACMR.

d) Consideration should be given to increasing the

involvement of the region specifically in that part of the

program relating to Chagas' disease which was found only

in the Region.

e) Efforts should be made to achieve better coordination of

actions between PAHO and WHO headquarters in relation to

this program.

3. Nutrition

A subcommittee had been set up to examine in more detail the

implications ot the presentations on nutrition and to make recommenda-

tions on what further needed to be done. All the presentations had made

it clear that protein-calorie malnutrition and other nutritional

deiiciencies continued to be major health problems in the member

countries. Eradication or amelioration of this problem was imperative as

part of the ettort to reach the goal of Health for All by the Year 2000.

However, this problem was linked with the level of social and economic

development which was attainable. It was agreed that the infrastructure

ot the health services provided the most appropriate vehicle for offering

protection to the groups at risk: this should be done through the

primniary health care system. The subcommittee emphasized that the presen-

tations, which hao been made, had shown that it was indeed possible to

- 44 -

improve the nutritional status of the risk groups without waiting for

definitive change in the socioeconomic status of people as a whole. It

was clear that the formulation, execution and evaluation of these

integrated actions required that there be permanent support for research

in nutrition and health services. The subcommittee therefore submitted

the following recommendations, which were accepted by the ACMR. It was

recomniended that PAHO should:

1) Give systematic support to the training of researchers in

nutrition and health in the countries, preferably in good programs in the

Region. This should be done by awarding fellowships and giving economic

and technical support to facilitate adequate institutional development.

2) Promote, support and strengthen scientific and technological

exchange in the field of nutrition between the countries of the Region.

There already existed in the kegion considerable expertise which could be

utilized in this manner.

3) Promote, tacilitate and support dialogue and interchange

between personnel involved in research, planning, and administration of

programs of health and nutrition. This would ensure that the results of

investigation were quickly applied to the development of action programs.

4) Channel some resources from external sources to the

development of action-oriented research in those fields related to the

consumption and utilization of nutrients.

5) Stimulate and support research according to the following

priorities:

- 45 -

a) Operational research - especially in relation to the

etfective and systematic incorporation of a discrete component of

nutrition within the primary health care package. This research should

be done with active participation of the health services and oriented

towards achieving functional integration of nutrition activities. There

should be emphasis on studies to find more effective methods of achieving

community participation.

b) Applied research - directed towards the possibility of

utilizing the existing health services for the prevention and control of

the nutrition infection complex. Nutrition surveillance should be an

integral part of the epidemiological health information systems. There

should also be studies on more efficient methods of nutrition education

for the community.

c) Basic research - on nutrition and its relationship with

intection, parasitic infestation as well as its effects on the individual

in terms oI social and biological functioning. The latter includes

studies on the etfects of nutrition on immunological competence, work

capacity, school performance, etc.

The ACMR recommended that strong support should be given to the

Regional Program of action-oriented Research in Nutrition. There should

also be acceptance of the strategies and plan of action which had been

drawn up by the Technical Group of PAHO/WHO, which had met in Bogotá,

Colombia, in June 1980 tollowing the recommendation which the ACMR had

thgiven at its 19 meeting.

- 46 -

4. Mental Health Research

The Committee referred to the presentation on mental health which

had been made earlier in the meeting. Note was taken of the wide

coverage which was being envisaged for mental health and it was felt that

there should be a better definition of the primary health care aspect of

mental health.

The Conmittee recommended that

a) There should be a regional initiative in this field.

b) Dr. Hamburg be requested to convene a study group to

explore the area as it related peculiarly to the Region

and to prepare the background material necessary to allow

a decision to be taken as to whether there should be a

regional research program and how it should be implemented.

5. Acute respiratory infections

The Committee considered the possibility of initiating research in

this area. It was felt that care had to be taken, that an increase in

proposals for research should not outstrip the capacity of the

Organization and the Region to accomodate them. However, it was clear

that acute respiratory diseases, especially in children, was a major

health problem in the Region. Dr. Acufla had already initiated

discussions in Geneva as to the feasibility of establishing a regional

program of research on acute respiratory infections in children.

- 47 -

The Committee recommended that a study group be set up to examine

the state of research in this area and the feasibility of a regional

program to deal with acute respiratory infections in children.

Dr. Robbins agreed to convene this group.

6. Cardiovascular diseases research

Bearing in mind the constraints regarding new proposals, the

Committee discussed the feasibility of new activities in this area.

Attention was drawn to the fact that in 1972 the ACMR had made

recommendations for further work in this field after the topic had been

extensively discussed.

The Committee recommended that PAHO staff working in this area

make a presentation to next years' meeting on the research being done in

this field.

2.9 Environmental problems and their relation to health

The CommitCtee disciassed the need for closer liaison between the

disciplines of environmental and public health. It was pointed out that

the ecological variability of the Region was a major factor to be

considered in looking at mortality and morbidity data.

The Committee recommended that for next years meeting

a) CEPIS be invited to make a presentation which would

address the issue of interdisciplinary collaboration in

- 48 -

health research. The previous annual report of CEPIS

should be precirculated.

8. Funding of new regional initietives in health

The Committee heard with great interest that agencies like the

Fogarty Center and the Institute of Medicine were prepared to entertain

requests which would permit joint approaches to research and research

conferences which addressed the major health problems of the Region.

-

Héctor R. AcunaDirector,. OPS*8 junio 1981

XX REUNION DEL COMITE ASESOR SOBRE INVESTIGACIONES MEDICAS DE LA OPS

WASHINGTON, D. C.

Al inaugurar esta reunión, además de la grata satisfacción de

extenderles mi más cordial bienvenida, deseo destacar que este evento

reviste singular importancia en la brillante historia del Comité Asesor

de Investigaciones Médicas de la Organizaci6n Panamericana de -la Salud,

al cumplirse en la presente sesión 20 anos de existencia ininterrumpida.

Ha sido, sin duda, sumamente útil tal continuidad, que ha prestado a la

OPS un apoyo inconmensurable en la revisión periódica del esfuerzo de

investigación en las Américas y en el asesoramiento de la proyección a

mediano y largo plazo de las bases cientfficas que han de orientar el

proceso de desarrollo de la salud.

Quiero expresar mi reconocimiento a todos y a cada uno de sus

miembros por la labor realizada y por la dedicación que ha demostrado el

Comité en sus reuniones anteriores.

Asimismo, permftanme felicitar al Presidente del Comité, Prof.

George Alleyne, quien ya tuvo la oportunidad de presidirlo en reuniones

anteriores. Deseo, también, presentar al nuevo miembro que hoy se

incorpora, el Prof. Frederick Robbinp, Presidente del Instituto c:e

Medicina de la Academia de Ciencias de los Estados Unidos, ampliamente

conocido por todos ustedes no s6lo por su magnffica trayectoria cono

médico, científico y profesor, sino también por su espfritu pionero en el

desarrollo de investigaciones en el campo de la salud.

* Organización Panamericana de la Salud, Oficina Sanitaria Panamericana,Oficina Regional de la Organización Mundial de la Salud

- 2 -

Igualmente, doy una calurosa acogida al Prof. David Hamburg,

quien aunque es miembro del Comité desde 1980, no le fue posible asistir

a la reunión del afo pasado debido a compromisos anteriores relativos al

cargo que entonces ocupara, de Presidente del Instituto de Medicina de la

Academia de Ciencias, como antecesor del Prof. Robbins. Me complace,

además, destacar la presencia en esta reunión, como observador, del Dr.

Claude Lenfant, Director del "Fogarty International Center" de los

Institutos Nacionales de Salud.

El crear condiciones que permitan a los países en vías de

desarrollo elevar el patrón de bienestar de sus habitantes es un objetivo

esencial, no s6lo por coincidir con los ideales humanitarios de estos

pueblos, sino también porque el desarrollo constituye, en sí mismo,

materia vital de interés político de estos paises.

Desde el punto de vista de la salud pública, el que esas

condiciones se hagan realidad dependerá de los logros presentes y futuros

de la investigación. Es precisamente para contribuir a este esfuerzo por

lo que nuevamente estamos aquí reunidos.

La investigación, dentro del programa de nuestra Organización,

se dirige primordialmente a fortalecer las posibilidades de los países

para llevarla a cabo, proporcionándoles los recursos que individualmente

no poseen, mediante la cooperación técnica con otros paises en

desarrollo. Estas acciones son un elemento intrinsico del desarrollo,

debiendo asegurarse que se mantenga en relación con las metas de salud.

,

-3 -

Por lo tanto, la investigación debe ser selectiva, enfocándose hacia

aquellos problemas con prioridad social. En el campo de la salud, como

en otras esferas del desarrollo, la rápida aceleración del progreso

científico general y técnico hace de la ciencia una de las más grandes

fuerzas productivas de la sociedad.

Las actividades de investigación en nuestra Organización

abarcan una amplia gama de acciones, que comprenden ' desde la

investigación básica productora de conocimientos y la investigación

relacionada con la aplicación de los mismos -incluyendo el desarrollo de

tecnología apropiada- hasta la utilización de métodos científicos en la

investigación y solucidn de problemas de salud en su contexto

socioeconómico. Sus objetivos serán el de investigar modalidades para

lograr el efecto económico y duradero más eficaz, mediante el desarrollo

de instrumentos, métodos y enfoques apropiados, principalmente para las

necesidades nacionales y locales y la promoción de la autosuficiencia

nacional.

En los últimos años, el enfoque de todas las actividades de la

Organización, incluyendo la investigación, ha evolucionado. El criterio

de la asistencia técnica ha sido reemplazado por el de la cooperación

técnica entre la OPS y sus Estados Miembros y de éstos entre sí, para la

promoción de la salud dentro de una perspectiva social. Todos los países

tienen capacidad para realizar investigación y están calificados para

colaborar con la Organización en ese sentido y obtener, a su vez, su

apoyo. Debido a las grandes diferencias cuanti y cualitativas entre los

Estados Miembros, es imprescindible que los mismos cooperen entre si para

beneficio de todos.

- 4 -

En la medida que esta decisión pueda ser puesta en práctica,

implícitamente están desapareciendo las diferencias que caracterizan

distintos niveles de desarrollo y la motivación central pasa a ser la

búsqueda de soluciones autóctonas, basadas en la creatividad propia y en

la eventual adaptación de los conocimientos y técnicas pertinentes,

siempre enfocados a la solución de la problemática local.

Por otro lado, el énfasis en la plena utilización de la

capacidad interna de los propios paises en vías de desarrollo, no debe

ser tomado como un rechazo del avance cientffico y tecnológico

proveniente del exterior. Representa, eso si, una sefñal de cautela en el

sentido de que ninguna nueva tecnología es válida "a priori" y que el

eventual compromiso de su adopción no debe competir con las posibilidades

de su adaptación al contexto local o con la potencial creación de una

tecnologfa más apropiada.

En este contexto, ciencia y tecnología asumen un papel

prominente como propulsoras de un nuevo desarrollo orientado hacia los

problemas que enfrentan los países de América Latina y el Caribe, tomando

en cuenta sus propias prioridades y en lo que sea posible, mobilizando

sus propios recursos.

El XXVII Consejo Directivo de la OPS, en su reunión del ano

pasado, aprob6 las estrategias regionales para alcanzar la ambiciosa meta

global de "Salud para Todos en el Afo 2000". Estas estrategias

regionales, configuran el cuerpo de las políticas de salud que orientan

los planes de acción que los Gobiernos y la OPS deberán diseñar y llevar

a la práctica como un compromiso solidario para alcanzar la meta antes

mencionada. Por lo tanto, proporcionan el marco de referencia para

nuestras actividades presentes y futuras.

-5-

En lo que se refiere a investigación, nuestra tarea necesitará

del renovado apoyo de los miembros de este Comité para que, de acuerdo a

los mandatos de los Cuerpos Directivos de la OPS, podamos definir

prioridades y promover programas regionales, asf como asesorar y orientar

a los países en el desarrollo de investigaciones aplicadas a problemas

prioritarios que conduzcan a lograr una autonomia científica basada en la

autoconfianza y la autosuficiencia.

Sefores participantes de esta XX Reunión del Comité Asesor de

Investigaciones Médicas de la OPS, sobre ustedes recae una gran

responsabilidad, ya que las discusiones que aquf se realicen y las

recomendaciones que de ellas se originen, no sólo van a influenciar 'la

programación directa que pueda realizar la OPS, en cooperación con los

países de la Región, sino que también podrán tener repercusiones a nivel

nacional, en la permanente actualización de los planes y programas de

investigación de los países mismos.

Este cometido es de la mayor trascendencia para mejorar la

condición de la salud y el bienestar de nuestros pueblos, e

indudablemente resultará en una fructífera reunión.

.. ,

Organización Panamericana de la Salud

VIGESIMA REUNION DELCOMITE ASESOR SOBRE INVESTIGACIONES MEDICAS

Washington, D.C.8-11 de junio de 1981

AGENDA

LUNES

8 de junio

SESION INAUGURAL

9:00 Apertura de la reunión - G. Alleyne (Presidente)

Palabras de bienvenida - H. Acuña

Palabras del Dr. S. BergstrOm

1. Situaci6n actual de las investigaciones en la OPS -J.R. Ferreira

10:30 C A F E

SESION 1: EnSeumedadeu DaLtrhcas

Mlodetadotr : J. KumateReiatot: R. Zeledón

10:45 2. El programa global sobre enfermedades diarréicas - M. Merson

11:05 3. El programa regional sobre enfermedades diarréicas - J. Rust

11:25 4. Avances en las investigaciones sobre enfermedades diarréicas -R. Black

11:45 Discusión

12:30 A L M U E R Z O

SESION Il: Invet¿gaci6n sobrte SeQrvicíos de Salud

Modexadot: H. GrootReZator: C.L. Gonzalez

14:00 5. El programa global en investigaciones sobre servicios desalud - S. Khanna (J. Castellanos)

14:20 6. Experiencia en investigaciones sobre servicios de saluden Colombia - G. Llanos

MARTES

9 de junio

SESION Ili: Investigací6n en Nutric¿6n

Pte,6dente: G. AlleyneReatot: L. Vargas F.

9:00 10. Estado actual de las investigaciones en nutrici6n enMéxico - A. Chaves

9:20 11. Estado actual de las investigaciones en nutrición enBrasil - Y. Gandra

9:40 12. Estado actual de las investigaciones en nutrición enChile - F. lonckeberg

10:00 Discusión

10:30 C A F E

10:45 13. Estado actual de las investigaciones en nutrición enColombia - J.O. Mora

11:05 14. El programa regional de OPS sobre "Investigaci6n Acci6nen Nutricio6n" - C. Daza

11:25 Discusi5n

12:30 A L M U E R Z O

SESION IV: Vaxios

Modexadot: T. WellerReatotr: D. Hamburg

14:00 15. Investigaci6n en el Centro Panamericano de Fiebre Aftosa -R. Casas Olascoaga

14:20 16. Investigación sobre el enfoque de riesgo en la saludmaterno-infantil - N. Suárez Ojeda

14:40 Discusión

15:00 C A F E

MIERCOLES

10 de junio

SESION EJECUTIVA

P'tu¿dente: G. Alleyne

09:00 18. Informe de la 22a. reunión del CAIM global -S. Bergstrom

Discusión

Programa de actividades para 1981-82. Comités ySubcomités

Fecha y lugar para la XXI reunión del CAIM de OPS

12:30 A L M U E R Z 0

14:00 Preparaci6n del informe final.

Pan American Health Organization

XX MEETING OF THEPAHO ADVISORY COMMITEE ON MEDICAL RESEARCH

Washington, D.C.8-11 June 1981

AGENDA

MoNDAY

8 June

INAUGURAL SESSION

9:00 Opening of the Meeting - G. Alleyne (Chairman)

Welcoming remarks - H. Acuña

Remarks from Dr. S. Bergstrom

1. Up-to-date Research in PAHO - J.R. Ferreira

10:30 C O F F E E

SESSION 1: Diautheal Diseases

.loderator: J. KumateReppo7tewut: R. Zeled6n

10:45 2. Global Program on Diarrheal Diseases - M. Merson

11:05 3. Regional Program on Diarrheal Diseases - J. Rust

11:25 4. Progress on Research on Diarrheal Diseases - R. Black

11:45 Discussion

12:30 L U N C H

SESSION II: Heath Services Reeatch

ModeA.tot: H. GrootRaPpoptew : C. L. Gonzalez

14:00 5. Global Program on Health Services Research - S. Khanna(J. Castellanos)

14:20 6. Experiences on Health Services Research in Colombia -G. Llanos

14:40 7. Report of the Operational Workshop on Health ServicesResearch - J. Ortiz

TUESDAY9 June

SESSION III: Nutr¿tion

Chairman: G. AllevneRappowIteuh: L. Vargas Fernandez

9:00 10. Up-to-date Situation of Nutrition Research in Mexico -A. Chaves

9:20 11. Up-to-date Situation of Nutrition Research in Brasil -Y. Gandra

9:40 12. Up-to-date Situation of Nutrition Research in Chile -F. Monckeberg

10:00 Discussion

10:30 C O F F E E

10:45 13. Up-to-date Situation of Nutrition Research in Colombia -J. O. Mora

11:05 14. PAHO Regional Program of "Action Research in Nutrition" -C. Daza

11:25 Discussion

12:30 L U N C H

SESSION IV: Vawiowu

Mlodeaato,: T. WellerRapporteuh: D. Hamburg

14:00 15. Research in the Pan American Foot-and-Mouth DiseaseCenter - R. Casas Olascoaga

14:20 16. Research Program on Risk Approach for Maternal andChild Health Care - N. Suárez Ojeda

14:40 Discussion

15:00 C O F F E E

WEDNESDAY

10 June

EXECUTIVE SESSION

Chair&ma.n: G. Alleyne

9:00 18. Report of the 22nd Meeting of the Global ACMR -S. Bergstrom

Discussion

Program of activities for 1981-82. Committees andSubcommittees.

Place and date for the XXI PAHO ACMR Meeting.

12:30 L U N C H

Preparation of the Final Report.14:00

Pan American Health Organization

XX MEETING OF THEPAHO ADVISORY COMMITEE ON MEDICAL RESEARCH

Washington, D.C.8-11 June 1981

-,

AGENDA

MONDAY

8 June

INAUGURAL SESSION

9:00 Opening of the Meeting - G. Alleyne (Chairman)

Welcoming remarks - H. Acuña

Remarks from Dr. S. Bergstrom

1. Up-to-date Research in PAHO - J.R. Ferreira

10:30 C O F F E E

SESSION I: DViorthe.a DQiVease

M,,Ioderatot: J. KumateReppoa/teuA: R. Zeledón

10:45 2. Global Program on Diarrheal Diseases - M. Merson

11:05 3. Regional Program on Diarrheal Diseases - J. Rust

11:25 4. Progress on Research on Diarrheal Diseases - R. Black

11:45 Discussion

12:30 L U N C H

SESSION II: Heath Sexrvice Researtch

Modea.~tor: H. GrootRappo0nteut: C. L. Gonzalez

14:00 5. Global Program on Health Services Research - S. Khanna(J. Castellanos)

14:20 6. Experiences on Health Services Research in Colombia -G. Llanos

14:40 7. Report of the Operational Workshop on Health ServicesResearch - J. Ortiz

TUESDAY

9 June

SESSION 1-ll: Nuit¿tíon

Charmunan: G. AllevneRappotteuwJ: L. Vargas Fernandez

9:00 10. Up-to-date Situation of Nutrition Research in Mexico -A. Chaves

9:20 11. Up-to-date Situation of Nutrition Research in Brasil -Y. Gandra

9:40 12. Up-to-date Situation of Nutrition Research in Chile -F. Monckeberg

10:00 Discussion

10:30 C O F F E E

10:45 13. Up-to-date Situation of Nutrition Research in Colombia -J. O. Mora

11:05 14. PAHO Regional Program of "Action Research in Nutrition" -C. Daza

11:25 Discussion

12:30 L U N C H

SESSION IV: Vaxiouz

M.odetatot: T. WellerRappo.teutw : D. Hamburg

14:00 15. Research in the Pan American Foot-and-Mouth DiseaseCenter - R. Casas Olascoaga

14:20 16. Research Program on Risk Approach for Maternal andChild Health Care - N. Suárez Ojeda

14:40 Discussion

15:00 C O F F E E

WEDNESDAY

10 June

EXECUTIVE SESSION

Chautmnan: G. Alleyne

9:00 18. Report of the 22nd Meeting of the Global ACMR -S. Bergstram

Discussion

Program of activities for 1981-82. Committees andSubcommittees.

Place and date for the XXI PAHO ACMR Meeting.

12:30 L U N C H

Preparation of the Final Report.14:00

THURSDAY

11 June

FINAL SESSION

Review and approval of the Final Report.10:00

-4-

15:15 17. PAHO Collaborative Study on Secondary Prevention on'-, Heart Rheumatic Diseases in Latin American Countries -

H. Boffi-Boggero

15:35 Discussion

17:00 R E C E S S

-2-

15:00 Discussion

15:30 C O F F E E

15:45 8. Studies on Social Sciences Applied to Health ServicesResearch - R. Badgley

16:45 9. Health Services Research as Component of Health ServiceDevelopment - C. Flagle

17:05 Discussion

17:30 R E E C S S

THURSDAY

11 June

FINAL SESSION

Review and approval of the Final Report.10:00

- 4 -

15:15 17. PAHO Collaborative Study on Secondary Prevention onHeart Rheumatic Diseases in Latin American Countries -H. Boffi-Boggero

15:35 Discussion

17:00 R E C E S S

-r

A-

-

-.l

~11

y

yá-

1-

- 1-

-2-

15:00 Discussion

15:30 C 0 F F E E

15:45 8. Studies on Social Sciences Applied to Health ServicesResearch - R. Badgley

16:45 9. Health Services Research as Component of Health ServiceDevelopment - C. Flagle

17:05 Discussion

17:30 R E C E S S

JUEVES

11 de junio

SESION FINAL

Revisi6n y aprobación del informe final.10:00

- 4 -

15:15 17. Estudio colaborativo de la OPS en prevención secundariade enfermedades reumáticas del corazón en los países deAmérica Latina - H. Boffi-Boggero

15:35 Discusi6n

17:00 R E C E S O

-2--4

14:40 7. Informe de la Reuni6n-Taller para la Operacionalizaciónde las Investigaciones en Servicios de Salud - J. Ortiz

15:00 Discusión

15:30 C A F E

15:45 8. Estudios de ciencia social aplicados a investigacionesen servicios de salud - R. Badgley

16:45 9. Investigaci6n en servicios de salud como componente deldesarrollo del servicio de salud - C. Flagle

17:05 Discusión

17:30 R E C E S O

Pani American Hlealth Orgarization

Organización Panamericana de la Salud

TWEN'llE'lH MEETING OF IHE

ADVlSORY COMMITTEE ON MEDICAL RESEARCHVlGEblMA REUNION DEL

COMIIE ASESOR SOBRE lNVES'LIGACIONES MEDICAS

Washington, D.C.,

8-11 June 1981

8-11 de junio de 1981

LIST OF PARTICIPANTS

LISTA DE PARTICIPANTES

PAtl ADVISORY cOMMITT1EE ON MEDICAL RESEARCH

COMITE ASESOR SOBRE INVESTIGACIONES MEDICAS DE LA OPS4-'

Members

Miembros

DR. GEOkGE ALLEYNE*

DR. GUlILERMO O ARBONA

DR. ROBIN BADGLEY

DL. CARLOS CELSO DE

AMARAL E SILVA

DR. JOSE RODRIGUEZ COURA

DR. JUAQUIN CRAVIOTO''

DR. JOHiN k. EVANS

Professor of Medicine

Head, Department of Medicine

University of the West IndiesMona, Kingston 7

Jamaica

Profesor de Medicina Preventiva

y Salud PúblicaEscuela de Salud Pública

Universidad de Puerto Rico

Campus de Ciencias Médicas

San Juan, Puerto Rico

Professor

c/o Committee of Sexual OffencesAgainst Children and Youths

Suite 1500

10 King Street East

Toronto, Ontario M5C 1C3Canada

Companhia de Tecnologia de Saneamiento

Ambiental

Rua Frederico Hermann Jr., 34505459 Sao Paulo, Brasil

Vice-Presidente de Pesquisa

Fundagao Oswaldo Cruz

Caixa Postal 926, CEP 20000Rio de Janeiro, Brasil

Director CientíficoInstituto Nacional de Ciencias y

Tecnologfa de la Salud del Nifo -DIFInsurgentes Sur No. 3700México 22, D.F., México

Chiet, Department of Population,Nutrition and Wlealth

World Bank1818 H. St.Washington, D.C. 20433

-

PAHO ADVlSORY COMMITTEE ON MEDICAL RESEARCHCOMIIE ASESOR SOBRE INVESTIGACIONES MEDICAS DE LA OPS

Members

Miembros

DR. GEORGE ALLEYNE*

DR. GUILLERNO ARBONA

DR. ROBIN BADGLEY

Dk. CARLOS CELSO DEAMARAL E SILVA

DK. JOSE RODRKIGUEZ COURA

DR. JOAQUIN CRAVIOTO

DR. JOHN R. EVANS

Professor of MedicineHead, Department of MedicineUniversity of the West IndiesMona, Kingston 7Jamaica

Profesor de Medicina Preventivay Salud Pública

Escuela de Salud PúblicaUniversidad de Puerto RicoCampus de Ciencias MédicasSan Juan, Puerto Rico

Professorc/o Committee of Sexual Offences

Against Children and YouthsSuite 150010 King Street EastToronto, Ontario M5C 1C3Canada

Companhia de Tecnologia de SaneamientoAmbiental

Rua Freaerico Hermann Jr., 34505459 Sao Paulo, Brasil

Vice-Presidente de PesquisaFundaçAo Oswaldo CruzCaixa Postal 926, CEP 20000Rio de Janeiro, Brasil

Director CientíficoInstituto Nacional de Ciencias y

Tecnología de la Salud del Niño -DIFInsurgentes Sur No. 3700México 22, D.F., México

Chief, Department of Population,Nutrition and Health

World Bank1818 H. St.Washington, D.C. 20433

Chal rliianPresidetite

- 2 -

DR. CHARLES D. FLAGLE

DR. CARLOS LUIS GONZALEZ

DR. HERNANDO GROOT

DR. DAVID A. HAMBURG

DR. JESUS KUMATE

DR. CAkLOS MONGE

DR. ALU1LO1 PKATA

DR. FREDERICK C. ROBBINS

Professor and HeadDivision of Operations ResearchDept. of Health Service AdministrationSchool of Hygiene and Public HealthThe Johns Hopkins University615 N. Wolfe St., R-7513Baltimore, Md. 21205

ProfesorDepartamento de Medicina Preventivay Social

Universidad de los AndesApartado postal 185Mérida, Venezuela

AsesorInstituto Nacional de SaludAv. El Dorado con Carrera 50Bogotá, Colombia

DirectorDivision of Health Policies Research

and EducationJohn F. Kennedy School of Government79 Baylston St.Cambridge, Mass. 02138

Jefe, Departamento de InmunoqufmicaDivisión de Investigación y EnseñanzaCentro Médico Nacional del IMSSAv. Cuauhtémoc 330México 7, D.F., México

Profesor de MedicinaUniversidad Peruana Cayetano HerediaApartado 5045Lima 100, Perú

ProfesorFaculdade de Ciencias da SaúdeUniversidade de BrasfliaBrasflia, Brasil

PresidentInstitute of MedicineNational Academy of Sciences2101 Constitution Ave., NIWashington, D.C. 20418

- 3 -

DR. ANDRES O. EM. STOPPANI

DR. LUIS VARGAS FERNANDEZ

DRF. lTI(jiAS H. WELLEk

Dk. RODKIGO ZELEDON

ProfesorFacultad de MedicinaUniversidad de Buenos AiresParaguay 2155Buenos Aires, Argentina

DecanoFacultad de Ciencias BiológicasUniversidad Católica de ChileSantiago, Chile

Richard Pearson Strong Professor

ot Tropical Public HealthHarvard UniversitySchool of Public Health665 Huntington AvenueBoston, Mass. 02115

DirectorConsejo Nacional de Ciencias y

Tecnologfa de Costa RicaSan José, Costa Rica

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WHO GLOBAL ADVISORY COMMITTEE ON MEDICAL RESEARCHCOMITE GLOBAL ASESOR SOBRE INVESTIGACIONES MEDICAS DE LA OMS

DR. SUNE BERGSTROM Chairman, WHO/ACMRDepartment ot BiochemistryKarolinska InstitutetSalnavagen 1S-104-01 Stockholm 60Sweden

OBSERVERSOBSERVADORES

DR. CLAUDE LENFANT DirectorFogarty International CenterNational Institutes of HealthBethesda, Md. 20205

PAN AMERICAN HEALTH ORGANIZATIONORGANIZACION PANAMERICANA DE LA SALUD

Otfice of the DirectorOficina del Director

DR. HtECTOR R. ACUÑA DirectorWashington, D.C.

DR. S. PAUL EHRLICH, JR. Deputy DirectorWashington, D.C.

DR. EUSEB10 DEL CID Assistant DirectorWashington,D.C.

DR. LUIS CARLOS OCHOA OCIHOA Operations ManagerWashington,D.C.

Nk.

DR.

DR.

DO .

Chiefs of Division and Special ProgramsJetes de Divisidn y Programas Especiales

FRANK A. BUTRICO Chief, Environmental Health ProtectionWashington, D.C.

cAklO V. FERNANDEZ Chief, Special Program for Animal HealthWashington, D.C.

JOSE R. FERREIRA Chief, Division of Human Resourcesand Research

Washington, D.C.

SUIEDHA KHANNA Chief, Division of Comprehensive HealthServices

Washington, D.C.

Jouk(;L LI'IVAK Chief, Disease Prevention and ControlWashington, D.C.

D) K.

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PAIiO'S Regional Advisors and Center DirectorsAsesores Regionales y Directores de Centros de LA OPS

DR. HECTOR BOFFI-BOGGERO

DR. CARLOS DAZA

DR. JORGE CASTELLANOS

Dk. JUAN CESAR GARClA

DR. RAUL CASAS OLASCOAGA

ENG(. JOKGE ORTlZ

DR. RLNATE PJ.ALUT

DR. JAMES RUSI

Regional Advisor in noncommunicablediseases

Noncommunicable diseases UnitDivision of Disease Prevention and

ControlWashington, D.C.

Regional Advisor in NutritionDivision of Comprehensive Health

ServicesWashington, D.C.

Regional Advisor in Medical CareDivision of Comprehensive Health

ServicesWashington, D.C.

Regional Advisor in SocioepidemiolocalResearch

Health Research Coordination UnitDivision of Human Resources and ResearchWashington, D.C.

DirectorPan American Foot-and-Mouth Disease

Center - AFTOSACaixa Postal 589 - CEP 20000Rio de Janeiro, RJ, Brasil

Regional Advisor in Operational ResearchHealth Research Coordination UniLDivision of Human Resources and ResearchWashington, D.C.

Regional Advisor in StatisticalMethodology

Hlealth Research Coordination UnitDivision of Human Resources and ResearchWashington, D.C.

Regional Advisor on Enteric DiseasesCommunicable Diseases UnitDivision of Disease Prevention and

ControlWashington, D.C.

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DR. GABRIEL SCHMUÑIS

DR. ABkAAMI SONIS

Dk. ELBIO SUAkEZ-OJEDA

Dh. BRYCE WALTON

Regional Advisor in InstitutionalDevelopment

Health Research Coordination UnitDivision of Human Resources and ResearchWashington, D.C.

Director, Biblioteca Regional de Medi-cina y Ciencias de la Salud - BIREME

Caixa Postal 20831CEP 04023 Sao Paulo, SP, Brasil

Regional Advisor on Maternal and ChildCare

Division of Comprehensive HealthServices

Washington, D.C.

Regional Advisor in Biomedical ResearchHealth Research Coordination UnitDivision of Human Resources and ResearchWashington, D.C.

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WOKLD HEALTH ORGANIZATIONORGANlZACION MUNDIAL DE LA SALUD

DR. MICHAEL MERSON Program Manager for Diarrheal DiseasesDiarrheal Diseases Control ProgramWorld Health OrganizationGeneva, Switzerland

REPRESENTATIVES OF OTHER REGIONAL OFFICESREPRESENTANTES DE OTRAS OFICINAS REGIONALES

DR. B. AJAYAWEERA South East Asia Regional OfficeWorld Health OrganizationNew Delhi, India

SPECIAL GUESTS

INVITADOS ESPECIALES

DR. ROBERT E. bLACK

DR. ADOLFO CHAVEZ

DR. YARO RIBEIRO GANDRA

DR. GUILLERMO LLANOS

Chief, Epidemiology SectionDivision of Infectious DiseasesSchool of MedicineUniversity of Maryland29 South Greene StreetBaltimore, Md. 21201

Jefe, Divisidn de NutricidnInstituto Nacional de NutriciónAv. San Fernando y Viaducto TlalpanMéxico 22, D.F., México

Catedrático de Nutriçao e HigieneAlimentar

Departamento de NutrigaoFaculdade de Saúde PúblicaCaixa postal 8099Sao Paulo, Brasil

ProfesorDepartamento de Medicina SocialDivisidn de SaludUniversidad del ValleApartado 2188Cali, Colombia

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DR. FERNANDO MONCKEBERG B.

DR. JOSE OBDULIO MORA

Instituto de Nutrición y Tecnologfade los Alimentos

Universidad de ChileCasilla 15138Santiago 11, Chile

Jefe del Programa de NutriciónFacultad de Estudios InterdisciplinariosUniversidad JaverianaCarrera 7 No. 40-62Bogotá, Colombia