W O R L D H E A L T H q1J1 ORGAN1 SATION MONDIALE O R G A N I Z A T I O N

REGIONAL OFFICE FOR THE -- BUREAU R ~ G I O N A L DE LA EASTERN MEDITERRANEAN M ~ D I T E R R A N ~ E ORIENTALE

Tenth Session mCGINAL: ~ G W

Hela at the Bourse du Travai1,Tuni~ Wednesdav. 17 hmst 1960. at 9-20 an

1. --- %ogrme and Budget E s t W t e s f o r 1962 fox the Eastism Mediterranean Region,

2, Technical Uttersr

a) Malaria Eradication in Eastern Piediterraman Hegion,

b) Mental Health in Eastem Mediterranean Region . c ) Kala-Azar (Visceral Leishmenniasis) In the

Eastern Mediterranean Region. . .

d) Public Health role in the disposal of radio- active waster

LIBYA

PiYIIST APJ '

SAUDI ARABIA

SUDAN

TUNISIA

w e s e n t a t i v e s

1,irh., Heilu Sebsebie

a d e d n Colonel P. Faure

Dr. I$ Etemadian

Dr. B,T, Diba

Isl., P. Khabir

'Dr, Farouk Par tow

Dr. k. Nabilsi

Ik, Abdul k i h n S , dl i i t u s q i

Dr, Ab&d Razak ldwani

Dr, K a n a 1 Borai

k, AdeZ Jamah

Dr. L.D. Khatri

Brigadier lfl. Sharif , Chaiman

Dr. Rassan Massif

Dr. T,' Ban SoZtane

UNITED KINGDOM Dr* ILII, Glynne

Observer

CYPRUS (Invited nonaember State) Dr. Z.G, Panos

World H e a t h .Or&#, za tion

Secmtapy to the Sub-Comdttee Dr. A, H, Taba, Regional Mrdctor

Deputy S ~ r e t a x y to the Sub- .k,. L.A. El BaZawanl, bputy Regional mrector Comdttga

United Nations and Specidized Agencies

United Nations 1.b. B. 14ereUth

UljRIfA, Heath mvieion Dr. S, Flache

UNICEF Mr. krdia l S. E l l o n

International Atomic bergy Agency

. . ... .. . . , ~ b s e ~ ~ e r C s , bf a t e r n a $ i d d , , : p~fi;-oomrnment;d, IrrterLdovemntd and XatiollEsl. Organizatiow

League of Arab, States ..- Ik, N, Nabulsi

b t e r n a t i o n a l Statistical HP. F d z KL X h d sducation Centre

IntemstiakJ. As~dbi&Uon Dr, Roger Nataf for the preventton of ~ l I n & e ss

International Union againat Dr.' R, 'Mjim2 yenereal Mseases aYld the Treponenatoses

World Medical. Asadciation fh.. hnrnussa

W t e d S b "Naval MedLc& U% N0.3 Dr.' J a n R'. S e a

E l y l u w ~ / h o g mm.1. page 4

1. PROPOSED PFiOQRWE AND $UDCfET ESTWTES FOR 1962 M)R TWE EASTEFW MEDXW?RMEAN REGION (Document E M / ~ c u / ~ ; agenda. item 9)

The R E G I O N A L , D ~ C ~ R said that docmmt ~N/h~10/3 ,contained

the proposed programme and budget estimates f o r 1962, the revised

programne and budget for 1961 and figures to hdicate the actual and . . antioipated expenditure for 1960. The 1961 programme had been . . approved by the Sub-Conrmfttee the previous year and by the IkecuKve

Board and the Thirteenth World Health Assembly. SZnoe it had been

approved, however, some revisions had been made withjn the appmved

budget t o t a l following reques.ta by Go+ernrnent,~ and dig cussions ,with

health authorities,

The doowant consisted of four main parts and three annaxest

the first part related to the Regional Office, the second part t o

Regional Advbers and WHO Representatives, the third part to country

progrmes and the fourth p a r t to inter-country programmes: , the f k s t

annex dealt with malaria progr~tmmeb, the second w i t h the cornunity

water supply programme and the thiA with additional woJec.trs whioh

had been requested by Quyementa but for which fund8 w a r e n o t

available. lh addition, -here was a small section dealing with

projects in the f onner British Protectorate of sbnqliland, h i c h had

on 1 July 1960 uniCed w i t h the former U.N. Trmst Terr5.t;ory of Somalia

under Italian A h h i s t r a t i o n to form the new Republio of Somalia;

it had fomerly been part of the WWO Afrioan Region but was expected

t o j o in *e Eastern Mediterranean Wgion once the Republic of Somalia

had become a member of WBO, The programme and budget esthates

s h m in the section had been &awn up by the Regional Office far

Africa.

The Sub-Committee would obsemd that 3 n the country pkgrames

section, the Technical Assistance 'mdget was divided into Category I:

and Category 11, The figures shawl: f o r 1961 and 1962 under Category I - the more @ p o r t a t park, - were in L few cases slightly different from

what h a original ly been submitted by governments, The reason was wat

the t a r g e t date f o r the submissio~ of country programmes t o the ~ochnic'al

Assistance Board was about the nliddZe of July, whilo the document under

consicl.era.l;ion had been completed by 1 July, The s.tructure of the Technical

Assistanc~ progrmme had barn gi-eatly improved by the fact t h a t it was

henceforward t o be drawn up on a biennial basis. That meant that it war

now possible to prwf cle more accurate forecasts f OP two years ahead,

and that the Technical Bssist;ance prograriP:le fitted in w e n v%th WHO1#

biennia l regular programme, Category I1 waa concerned with ~ r o jscts.that

had been suggested by g o v e m n t s but wMoh, due to the shortage of

Technical Assistance Pun&, were very unlike;ly ' t o be implmlented. It was

nevertheless useful to include them 3n the documant, since* if the Sub-

Cawittee approved than in prLncipla, they could be substituted for

Category I projects which were delayed for one reason or mother,

The atra-Buc3p;e.tary column reforred t o fbnds which were neither Regular

nor Tochnicd Assistance funds, Pfost of the sums mentioned came from

UNICEF, and those that trera .marked with an asterisk had drear?'$ been

approved by the UNXClP kecut iva Board.

He wished to draw the Sub-Committ~e~a' attention t o t he additional

assiatanco that was being .provided to Cyprus, ICtlwait and Sor,dia out of

a special allocation f o r assistance to new ~ieribers and associate members

of FEIO tha t had heen provided f o r in Resolutfon WHAl3,29 of the Thirteenth

tiorld Health Assembly, In that connection, he &so wished to draw %he

~ l , m C l ~ h / P r o ~ , N L n . 1 page 6

Sub-ComiStee s attention t o the proposed supplement &I. Technical 2ssistance

progrmke for Cyprus and Soml la contained in document m ~ / ~ ~ 1 0 / 3 Md,l,

The programme' s t i l l had t o be approved after discussidn a t the country

Referfine; t o the su~iilary by m i n subject on pages 10 and 11 of t h e

principal document, he pointed out thc t a cer ta in mount of overlapping

between t h e subjects l i s t ed w a ~ inevi table in view of the fac t that

it was frequently impossible t o make a clear-cut d i s t i nc t ion between

the various -f ields ' of woork* The budgetary ~ ~ o v i s i o n s f o r education

and trainfng - particularly f o r feLXcwships - showed a marked

increase,

On the- proposal of the CHAIPJWI, it was agreed that the document

be exmined section by section,

P a r t 1 - Regional Office

The R E G I ~ J I U I DIRECTOR sa id that the budget for t h e Regional

Office Ln 1962 was the same as that f o r 1961 except f o r the addition

of a post of a c lerk librarian.

Part 2 - Regiondl iidvisers and bHO Representcatives

The REGI3NAL DIRECTOR said tha t t h e pdsts proposed f o r 1962 were

largely the same as in previous years. Two new posts, however, were

prb~osed fo'r Public Health and C o m n l t y Dorelopment. These wou ld

replace the ad-vtser on Bilharziasis whose work would be taken over by

the Daputy Regfond Erec to r , and one of t h e Nursixg Advisers. It had

also been considered advisable to appoinb a Regional Addser on Radiation

and h o t opes,

Dr. F W (Tunlsia) askad whethor the Fkgiond &rector could supply

the meeting w i t h MX further information with regard t o tho new pos t of

Addser on Community bvelopmnt and vdth regwd to WIIOls genera3 policy

Jn tha.t field,

The RZGIONIG DIRECTOW sa id that many Community Development progranmee

wero being sponmred b;;; various United Nations Agencies, and that Wlero

had been requests that WO should advise on the public health aspects

of such progrmles, The Adviser, on Commmity 13evelopner.t would thus be

appointed, partly in reeponse to those requests, t o visit Oountries'

pihero (bmmrdty hvelopmetri; pro jecte were under way in order to advise

on t h e public hetilth aspecta,

Part 3 - C o u n t r y P r o g r ~ ~ s - .

Dr. DIBA (Iran) said that hie country ~Lshod .to request the RsgSond

?&rector to make every effor t to f i l l the posts shown in Iran's progrqm

as aonn as possible,

The REGIOHAL DIRECTOR said that the Office a l w a y s tried Lo fmplement

grogrames exactly as they were drawn up, Tllere were, however, many , ,

difficulties connected w i t h the recruitment of qualified t e c h n i c d

pweonnel acceptable to the countries concorned which led to delays in

such recruitment. Eharything would be done, however, to meet Iran's

Dr. K H N R l ( ~ b y a ) s a i d that if the Tuberculosis Control and Demonstration . .

Centre wm set up in Tripoli, instead of Bonghazi, a laboratory technician

would be needed fmm tho outset, and for that roaaon he hcped that it might

be possible f o r the laboratory technician mentioned on page 83 to be moved

f r o m Category If: to Category I, He also hoped tha+ it would be poss2ble

t o provide a t h i r d nurse t u t o ~ for the Nursing &cation Centre in Cyrendca

which was due t o open . S1-.:196X,

The R2,GIi31.Ii;L DIRECTOR said that he trould make every effort -to met

the W.>yan request, although it ~ ~ g h t be d i f f i c u l t t o do so in view of

the shortage of Technjcal Assistance f'Unds. So f a r as the labomtory

technician was concerned, a possible solut ion was f o r the Kbym Government

t o a?ply f o r a grant from the Technical Assistance contingency finds, at

least for the bienni d. 1961/62,

Dr. NRSSIF (Saudi Arabia) said that the mention of bilharziasis

i n f ec t i on among p i l g r i m returning from IaIecca on page 100 of docwnerrb

E ~ I / R C I O / ~ was tnaccurate; the danger of in fec t ion among the pilgrims

did not e a s t .

Hia Government hoped tha t the appointment of the Public Health Y~cfviser

(page 103 of the document) would be extended for t he whole of 1962, He

had been concerned to learn from t h e Regional B r o c t o r t h a t the Technical

bssietance au thor i t i es intended t o transfer the Blood Bank projfet at

Riad (page 307 of t h e document) from.Gategory I to Category 11, and

earnestly hoped that it would be possible t o retain it in Category I,

The REGIONAL DIRECTOR sa id that he was in entire sppa thy with t he

last two points raised by the Delegate of Saudf Arabia, and tmyld, for

his part, do a l l that he could t o ensure that t he wishes of S a u d i Arabia'

were met,

The DEPUTY NGIONIIL PIRECTOR, referring t o t h e first point raised by

the &legate of Saudi Arabia, said that he agreed t h a t the danger of

bilhmziasis infection with pilgrims returning f r o m 1-lecca dld not exist,

The danger arose when p f i g r ' h wandered through other parts of the country

where there was a danger of infect ion, The Regional. Office intended to

send a short-term consul tant to ex- t he problem as a whole*

b. W (Sudan) said that, 3J1 the dental health programe for Sudan,

what was required was kt a consultcat but a dsnbDl sudgson, wha apoke

b a b i c , t < o take oharge of the school far d~ntal. assiatarrts In vS.8~ of

tha fact that it w o u l d not be possible to set up the Radisbio; and - * *f

1 s o t 6 ~ e e ' s e ~ o e for the ib 'being, the Hadiologist for that sellrice

would not; be ppquimd, and he wondered whet her the money .thus saved could

not be used elsewhera - far the dental Elurgeon he had mantionad, for

oxamale, or for further fellowship, b recalled that his counOry Md

requested a pubUc health consultant and a aaruitmy e n g b e r f o r the

mlfa reerottlanent projoot, and he hoped that it would be poss ibb for . .

those experts to be provided, at least by I9621 ~~, he would be

grateful to know whether %he Regional Ukector considered it posslbJ~ to

mka proviaion in the current bud.& for Ilmphmenttng the project agalnst

the spread of bilhar~iasis in Northern &adan,

The REG:clUkL UIRETCEi said tha t ha would be pleased to &.a cuss with

t 'na UeZegate of Sudan tha possible uses t o which the savings from the

n b ~ r e c r u i ~ n t of the radiologist could be put.

he l?iW (~un la ia ) said that, in view of tho valuable wrk tk*

had been underbinken by the vlxologist in the OphthhologicaZ Centre at

Tunis, h~ hoped that it would be possible f o r that exprtts appoinhent

to be prolonged fo r a further yoar in l96$. Wa also hoped that it might

be possible for the aecond six months of the Public Haalth nnrseis 1w appobtmnt (page 127 of t he document) to be transferred from Category I1

The R l B I O I U URF,CTa pointed out, with regard to the virologist,

that L t was WHO polioy f a r Technical Aasistac~ experts t o train b c a l

staff to be able to take over the projects on which they were ~ $ k L q r

Thero was no doubt, h o m e r , that the virologist was angaged on excep

t iona l ly +&ant and clolwpl~x work, and for that reason he was preprod

to agroe in prilzcipu to the Tunisian request. Should tho corut;Uuation

not prwo possible f r o m the reg iowl funds, t h ~ n the m a t solution

would be to try m d obtain the necessary funds from WHO Leearch finds,

since the project was essontLalJy a resaaroh one,

With regard t o the Public Health w s e he pointed out that the

new b icmla l pxagrmn5.q made it possible f o r savings in one year to

be carriad over and spent in the next On Wt basis, it might be

p o s s i b l ~ t o accede to the Tunisian request.

Inter-Country Programme

The RGGIONAL DIBECm said that the rural housing project in public

health administration . . (EMU-46) was a new venture. It was proposed

that in 1962 an expert should carry out a study on the ways in which WIO

could give assistance with housing problems, particularly as regards i t a

health aspects - the de ta i l s of the programme had not been worked out as

get.

Dr FAMI (Tunisia) asked whether the period of a h months allocated

for the study would be suffioient.

The lBGIONAL DIFZCTOR explained khat me p&od of six months

referred only to 1962. Itwas proposed to survey two countries with

different cultural backgrounds in 1962 as a sample* The program8

would, however, probably cbntinue for several years, and since t h

Committee seemed to approve the idea in princtple, it might even be

possible to make a start in 1961.

The p ~ o j e c t for assistance to medical libmries ( W - 5 5 ) was also

.new. The literature at medical libraries was often incomplete and out

of date and variow countries had requested advice on how to organize

W improve their medical libraries. The new project was intended to

help ministries of heal* and medical ins-kLtutiana to establish

libraries or to improve &sting ones. One or two countries would be

dealt. w i t h each year, on a con-kLnuimg b a s h . The order of priority

would be based on comtriesf requests and the scient i f ic status of We

libraries in questxon,

The trainbig $ourere f o r labbratory technicians (EhRO-61) and

f ellonships for a&or medical eduoatore (EMRO-69) werb b6tb list

projects planned for 1962. The purpose of .the l a t t e r was to

enable such people as university lecturerb wi professors ~ aiudy modem trend8 at academic institutions h countries where publio

heaLth education was.wel1 advanced. It related only b educatars,

not, .to adminisk.&ive , wo~kera . Dr IUUTRI: (Libya) asked whether the tPaWng oourae for

laboratory t e o h n i c k would be held i n each cauntxy or at a single

The REI)IOW DIRECTOR a ~ i d that no definite programs had yet

been esWUahd,~ :but ,&t was. . w c t e d that +he course woyM be held - L . .

. in %,but, where there was .a . good nationst1 oentxal laboralmy.

-Ap'glt$o%t,ionls would be invited from a l l count~ies of the Region and

S U W , ~ S ? ~ ~ , candidates . , - be givm f dlWShip8 WHO mt&d . .

provide ,No , laboratory technician sduuatorn to aid the Lebanese

staff, am3 would alao supply equipment,

Dr - , (kan) pob,ted , . out, tha$ the language in tjhich the

ns>urs.s was ,,to be given 4hquZd . . be, indicated tn advance so that

appropriate fe&l,ws co@d.be, selected.

!Che..mIONAL DIRECTOR s&d. t he t governments would be informed

w h a t language was t o be used.

Dr PAIEmW (,Iraq) ,ask@ ,+ether it would be, possible to appoint

pa teohnioiwn or adviser .in veterfnaru public health on a regio-1

:basis.,. "Iraq and other c&ntries auffqrad mrn animal diseases the k m e ~ ~ u e ' e p ~ e m i c fbeL m e thir y e a

orhi.& h s y o d d a @ m l W mi emn& p r o m a , The- REQIONAL , D I ~ C T Q R recalled that, two yeaxa previously auoh

an adviser had. been, , . . appohte! ,, , for ,one year and after f ia i t ing the

countries cwerned had submitted reporb on the main problem,

whioh had bean sent to governments. The post had been diaconthued

since other services had been considered more important but it m i g h t

be possible to re.res tablf sh , it in. 1963 .. &l.arja Eradication Aotivities

I& SEBSEBIE (Ethiopia) said that the malaria training centre

in his country was doing magnificent work and his Qovement greaCly

appreoiated the assistance of WHO,

Dr WIISI (JoPdan) said that the westem region of Jordan waa

~0mplately cleared of malaria and it was apeclad that the disease

would be eradicated from the whole country with in three or four

years. He hoped that WHO would continue its assistance.

Dr KHAllTlT (Libya) recalled that only some 10, #O people in his

country were in danger of malaria. One sanitarian had been s e n t k

the endemic area and two more were being trained. H8 asked what

would be the functions of the technician whom it was pmposed to

send to Ubya (Libya-9).

The RlBIONAL DJRECTOR said tht the post had originally been

intended for a sanitarian but since Libya now had enough sanitarians

the CSovemrment had proposed that 'a laboratory technician should be

sent instead. The exact nature of the poet would be finally decided

in consultation with the Government,

Dr FARIP, Public Health Administrabr (Maria) , said that the

t e o h n i c b would probably take charge of the sweillwnce propame

and would. have w i d e qualif icatiops , partl~uX&gly $9 blood a ~ l p , i s :

and entomology.

The CHAIRMN, speaking as representative of Pakisw, said that

his country would like some eartra-budgetary assistance in view of

the great cost of its programme.

Dx-.NA59IF (Saudi Arabia) said that no, pro.vigion had been mads

f o r assistance la his ,countw in pre-eradimtion activities a-r

1961. H i s Jkverntnent had planned to snt;aY.t eradication in 1962 bu%

thd pk-eradication a w e y might not be oomp1,eted in time. It was

to be hoped tha t aid would continuo to be given for pre-eradioation

as long as it was neeessay.

The REGIONAL DTH3CTOR said that if the pre-eradication survey

in Saudi Arabia was not finished in 1961the ~ u W al located for

eradication proper would be used f o r pre-eradication.

Malaria Inter-Countq Pro~ramme

The R E G L O W DIEECrnR said that the pwpoae of #e trailling

c m a e for mala rb teama (EHRO-70) was to remedy the shwtage of

traiaed workers and pa~ltiLoularly of those familiar d t h new

techniques. Persons already q d 3 f ied i q a particular f i e l d would

be given in-service training on one of the large-scale erdioation

projects in order to ramiliarise them with all asMcts o P the

subject. They could then act as advisers. The poata wouldbe at

the +2 level because those concerned muld have trainee status.

Dr GWME (United Kingdom) said that it was importah% tha t the

financing of the whole malaria eradication Fogramme should be

gummteed. Under the present voluntay aystem contributiom for

19.60 fell short by $ 1,000,000 and no contributions had been

received f o r 1961. It would be better if the program &re

financed $ram t h e regular budget of WHO.

The REQTOM DIFECTOR said that recent contributions had

reduoed the gap f o r 1960 and pledges had been made for 1961 by

various countries, including the main contributor. The financial

outlook was, however, unsatisfactory, and it might be advisable to

re-consider the system of voluntary contributions. The Director-

@hem1 of W30 htended to report on the matter at the n w t World

Health Assembly. It might be necessary to include the programe

in *he Regular budget, but that would en ta i l a substantial lncrease

in assessments of tho member countries.

Dr G M W E (United Kingdom) pointed out that if the progradme

were included in the Regular budget it would affect tho order of

prSority in the budget estimates.

The REGIONAL DIRECTOR aaid t h a t no decision codd be taken .on

that question by this committee as the matter was f o r the Assembly

to decide.

Community Water Supply Programme

There were no comments.

Additional Projects

There were na comments.

The CHAIRMAN asked if there were aw general comments on the

i t e m

Dr GUNklE (United Kingdom) obsemd that there was a tendency

for the budget to hcrease automatically by 7-10 per cent. every

year. There cowl8 be no doubt that the programmes served a

humanitarian purpose nor that the Regional Direotor examined any

proposed projects very carefully, but i t might be profitable to

make an evaluation of all projects, as was done with the fellowahips

programme, in order to ensure that the moneywas spent to best

advantage.

A8 r e g w e Tedhniowl A~ieristmoe, several oounWes had asked

for projeots t o be 'transferred frbm batego* 11 tb Category .I on

la& 09 funda. It might be advieable to stipulate that Categcry I , .

pro3aots should be oapable of completion within the yeG-far which

funds were allooated, so that they did not p m m t the f3nple;mentatior~

of profitable' schemes in Category a.

The REQIOW DIRECTOR said t h a t the werall budget was a matter

for the World Health Assembly to decide, on the barsia of reqonmrend-

ations by the Director-General. The Regional Conmiittee wa'd only

competent to . review the budget for the Region. A cerWn fncrewe , f

each year was inevihble .and was felt to be et heal* .trend, 5f WHO

i a t o maSnWn its dynamfo,work. The budget wae preparedon the

b a s k of the general policy laid down bgp the Aseembly, taking i n t o 2 I > I '

account the vims of govemenlx3.

me ~~ pmposd the f o l L m i q . draft reeolution $or the

attentLon o f the Committee.

~ t P R O C ; W AND BUDQET ESTWTES FOR 1962 AND S m m T A L 'IBCEIWICAL ASSfSTANm PBOOFiAl@E

FOR CYPRUS AND SOMALlA

The Sub-camittee,

1. H a w wnsldered the proposed pmgrarrrme and budget astimatea

for 1962~ submitted , , by theRegiona1 Director,,

B a a r i n g in mind a e particular need# of new Sta-tea for

assi&noe in We field of health,

1. ENDORSES t he propoaed programme and budget e s t a t e s for 1962

to be Smplemen.t;ed from the Regular Budget of the World Health Organisation, the Eaqanded Progranrme of Technld Asshtanoa funds,

m / R c z o ~ h g . m. L page 16

the Malaria Eradication Special Account, and the' Special Account

f o r 'Comuxiity FTn.tgr Supply (aub-account of the VoXuntaxy Fundl f o r

Hea Jth Promo tion) ;

2. EXPRJMSES its4apprqciation of the contbued emphasis placed

on communicable diseases, environmental sanitation, menkal health,

nutrition and fellowships

3. NOTES .with satisfaction the additional assistance under the

Rewar m&et proposed f o r new members and associate members and

newly Mepndent .and emerging States of the Region d e r resolution ,W.U..29 of the Thirteenth World Health Assembly;

4. THANKS UNICEF f o r i t s continued cooperation;

11. Kav- studied the document on the Supplesnenbl Technical 2 Assistmoe Prograxrme for Cyprus end Somalia pkesented by the

Regional DirecMr,

1. RPFROVES ' .the prupplemenlal programme for Qprus and Somalia,

proposed by the Regional Director under the w a d e d Progrme of

Technical Assistance ;

2., REQUESTS t he Regional Directur to transmit %his proposal thmwh . . the usual channels, to We ~e'chnical Assistance Board for consider-

ation by the Tschniml Assistance Committee f o r imp1emen.btion

provided the required additional resources are made available in

accordance with its constitutional procedures.

Dr KHR'PRZ (~ibya) proposed that in the second operative

paragraph of part I the word llfellowshlpsu hould be replaced by the

words Iteducation and training ' 1 .

It was so agreed.

Dr MASSIF (Saudi Arabia) proposed that ixl the Arabkc tat, in

the first operative paragraph of part I, the work ltkhairytt s h d d

be replaced by Iriradyft, as a translation of "voluntary1'.,

,It was so. agra,e@.

Hmazia,. as. .amended, was @opted unmimously+

The meeting was supended a t 11.25 a.m. and resurmed a t U.45 a,m,

-mJX EXUDTCATJ;ON ~U~ T?d THE US- MEDITEHW$Al,. REPION (item $O(a) of the agenda)

Ds F A m , , Publicp; H e a l t h Amhis tratar (Malaria), h-dudng

the report on malaria eradication programea in the E a - s u $ e ~ . Nediter-

ranean Region , (EM/~cJo/~) paid that it,. g@ve ,a s v Govements

;e#'Zom, h- -;&aria eradication,: and of. the work- of the 'bg io la l Off i c e

-b- providbg- advisory ,serviggs ami .fellqships, proneo ting -sew&

i n t o - technical prqblm; and;,coordinat'ing wctivitie,~ wer *e. yhole

field. The World Health OrganLsataon and the Regional Office

depended on the guidance and support given by the i r members in order

to carry out their task.

The experience gained by Wvemment~ during the last five years

was Sndioated by the recommendatiow made by the second b g i o n a l

Malaria Eradioation Conference held in Addis Ababa in 1959. , noae

recommebdation.8. revealed that hvarrrments now pd~sfpodG,tb

prhckplas of eradLcation and had aroused great interest Wopg

sci8tnItists and in4;erna tiom1 orgadsationa . They had been

published in\WHO Malaria BuZZetU No.265. There waa no longer any

need to persuade hvsmrments to change over from the system of

.malar$a control' ts .that of eradkoation. The latter w e less.

q e n a i v e ar&led t~ therestablishment of administrative ma&herg

which wuld be wed t o deal w i t h athep diseases. EWw coWWy .In

the b g b n was either c a w i n g o u t a r p l e b g kradication, Those

~ 1 0 ~ ~ m g m* 1; page 18

countries where malaria was endemic had rsalised thaC it was

impoesible ole plan for reoo~omio and bboia l development until We - .

th reat of the disease was removed; Con%rol alonev was not adequate

t o prevent t h e deaths and t h e economic ham caused by the diseasa, . .

It was essential that the efforta of individual GovePments

should be integrated on a regional and world-wide basis. The

Regional Office sought to achieve that a h by coordinating projects,

circulating information, and promoting research and =changes of views.

It encouraged agreements for joint activities betweoh countries with

Satisfactmy progress had been achieved in malaria eradication

activit ies in operation for some four years in six northem countries

of a e Region, extending from Iran to Iabanon where 22+5 million

persons were in danger. Some pockets of resistance still remained,

huwwer, and it was essenfial that, Governments should 'not alacken' their

efforts now tht t h e end was in sight.

Annex I11 of the report descrtbed operations in Iran, Iraq,

Jordan, Lebanon and the UAR (Province of Syria), Libya had star ted

eradication in t h e current year and the UAR (Provinoo of Emt) intended

to do so in 1961. Weaknesses and difficulties hadnot been omitted.

The maZn trouble was t h e inadequate administrative and financial

resources allocated to the organizations responsible for eradication.

Those organizations must be givan the means to camy out their projects

and must have the full cooperation of the administration and thopublic.

Internatioqal . organizations ,,. had recently adopted the policy ' of

stipulating that before an agreement to give assistance was drawn up,

+he abi l i ty of the natLona1 health aervices to carry out the p w g f a m e

must be damonstrated and the Governwit concerned mwt make a carnib

ment to provide the necessary finance. Proof must also be given of

E M / ~ I O A / P ~ ~ ~ m . i .- page 19

the coun-kyts abil ity ta prevent re-appearanoe of the dbeaae after

f t a er&dioa%fbn and an amwl evaluation of the progress made n u t . .

be carried out. That procedure mdld a m r e tbt onlyworthwhile

!he repoxt reviewed eradication aotivities which had beon in

operation for a year or more in Pakistan, Saudi Arabia and Tunisia.

The ope~ations in Pakistan and Tunisia shouAd be ooropleted by the

end of 1960 and those in Saudi Arabia 4y the end of 1961. Thw a l l

the A s i a n countries in the Region, except Yemen, * b e Aden Pro teobrab ,

Oman,, Qatar and Bahrein,. came withb . the framework of the eradication

Pilot projects. carried out by Ethiopia, Sudan and Somalia had - . !, j .

shown that t h e dangerous moaquito A. Gamblae, which had poved .I . .

resistant to many . insea-bicides, could be el-ted by thorough bJ . :

spraybg . of all dwe1J.hgs with DDT. Comprehensive 8-13 would

soon e ta r t in Ethiopia and Sudan, which had established special

departments for malaria eradication.

It wals gratiaing to note . , the presence at the session of the - , . A , , . ,

representatives of Kmi-h, which was f r ~ c from , , malaria, and Cyprus, , , . - -. ,

which had been fYee ,since 1948.. .: , Somalia,, where the disease was - , . , ,.

endemic,. was to undorVt;ake a.giLot ppmject on eradication methcda .to

be wed amongst nomads.

Great attention was paid by the Roglonal Direotor t o the training

of malaria staff. Details of the oentres established and the

fellowships awarded were given in the report. The number of trainees

was expeated to be sufficient. The RegionaX Direotor also attached

considerable importance t o the solution of technioal problem. An

a m p l e given in the repopt waa research into t h e rosiatance of

malaria vectors to bect ic idea . That research suggested the need

t o avqid bhe development of,rssistance through the use o f . , , . , . .

insecticides f o r agricultural purposes or locust control. Another

t e c h f cal problem under imes tigation was nomadism. M,ethods

adopted in that comexion included the training of youths to accomparU.

nomadic tribes and carw out surveillance mrk, distribution of drugs,

the spraying of huts with inseckicides and the m k h g of an t i tda r i a

drugs with b b l e salt. The last method had given good results and

was to be generally adopted.

The Regional Office was urging Governments to s e t up departmsnts , .

for .health pmpaganda and education i n order to mobilize the. whole, .. , , ,

coun- in the struggle against malaria. Health education was.

included as a . subject . h all .training,courses f o r malwia workere.

The Regional . . . . > . Director . . had put into af feo t the pesolutio~l,adopted by . . . , .

. . , , . , ,.

the Committee a t the previous session regarding the estnblishment of

an international .team f o r t he evaluation and coordination of

activities in neighbowing oountries. The team had .bhe task o f

studying the epidmiology of the disease, partimlarly ip resistant

pookets, of coord ina thg operations on bordws between countries

and providing Oovomments with advisory services,

Fhally, he thanked Qwemments for their cooperation in

carry* out the international malaria oradication pmgmrne*

Dr,l(HABIR (?ran) amphasized the importance of the malaria progranrme . !

in the Elegion. . In . his , country, the Malaria Eradioation Programme was

given top priority not only in the health sphere but also in the e c ~ n d c

planning of the country. The Plan. . Organization, aware of the parmmnt

importanoe of the matter, aUocated @eventeen million dollars of its

public health funds to .. the, . cause, . ,

Malaria control work @d ataxted > . , in W&. The first years had been

devoted mainly to a tuaes and surveys, The eradication campaign proper

,had started in 1957 and the target date for the eradication of malaria

throughout the country was 1961, by which t i m e spraying operations would

have.covered every cmmmnity, In the year under r0v%ew, malaria

exadication activit ies had proceeded in 34,051 villages . l 109 760 @

2 of lneecticides had , ,. been used and 438 572 000 m had be*. ,+wered . .

27 883 yiUagee with a population pf , 7.768 . . 687 were b e i q ,kept .Y-,

m a i l l a n c e,

With such a campaign in process, though maw di f f i cu l t i e s were being

encountered, it was hoped that the never ceasing fight against the - *

enemies of the comtryt s health would be ca r r i ed t o its final stage . . of

eradication.

The problem encountered inchded the resistance of A. stephemi

. in Southern hen. mat waa being countered with WHO assistance. . .

13islM.n resistance was present in isolated vi l lages but was not l i k e l y

t o develop i n t o a regional pxobleon, Difficulties were gradually being

overcome and the c ~ ~ a i g n was proceeding smoothly.

Reference was made in t h e document under discussion ( h e x 311, p g e

3 ) to financiw problem, All of then had already been solved and the

few remaining were being surmounted.

As the spraying operations were soon to be completed, the t h e had

cme for a technical evaluation of the programme in Iran before transition

~ ~ ~ 1 0 ~ / 0 r i r r / ~ n . 1: Page 22

to the surveillance stage which would last for seve~al~~eara. ' ' WHO

assis%ance in that, regard had heen received but it 'would cmtinue to be

an important factor especially aa the Plan Drgardzatlon was preparing its

f ive-xear budget. , , - ,

He then expressed h i s appreciation of WHO assistance and expressed

the hope t ha t it would be continued in 'the future,

Dr BAHRI (Tunisia) said t h a t the .significant progress his country

had achieved was very largely due' t o the existence of a ' comprehensive and

polyvalent health service covering the entire country,

At t he b.asls of tha t structure were 25 partially or fully i t b e r a n t

male nurses, Their ac l iv i t iea covered a31 Tunisia. The part ialu

i t i ne ran t ones covered their areas fully once every f orbnight and. the

totally itinerant ones, every week; tt-amport was generaw by t scooter.

A 1 1 were fu l ly trained to recognize communicable diseases and to prepare

the necessary samples for laboratory analysis. They were i n close

contact with a l l strata 09 the kra3. population and were valuable sources

of health education. After the labo&at&y diagnosis, it-was they who

carried out t h e necessary preventive and curative measures, Thus, the

appearance on Tunisian t e r r i t o r y of any communicable dismae was invariably

detected a t any rate between eight and fifteen days a f t e r its appearance.

The activities of the i t ine ran t male nurses were coordinated and

controlled by regional medical supervisors who assembled a11 e p i d d o l o g i c a l

&%a and screened it f o r s u ~ s s i o n to the chief public health officers;

they decided what action should be taken, lJeekly reports from the regions

were sent to health authorities for use 'in the preparation and

supervision of malaria work.

He then described the act%& taken by the itinerant mrss when he

discovered a case of fever,

There mre a t present five haematological laboratories for the

examination of the slides prepared by t he nurses and others were soon to

EM/RC~OA/P~ og/-mn, 1 Page 24

larva control. That had brought the incidence of malaria down from ' I - .

, .. - . . 15,932 poeit.i.ve slides in 1934 t o 5,601 in J.937. Stat is t ics ware

lack* for the war years and were available again frm 1 9 U onwards.

Unfortunately, the slowing dawn of prophylaxis, and lack of drugs had

coincided with a number of years with a particularly high rahfall so that

there was a recrudescence of the disease - 3,7U cases in 1945 and 16,166

in 1948, Larva control and mass chernoprophylaxis with modern synthetic

drugs of proved value had to be resumed as a matter of urgency and in 1949

the malaria budget was about 100,000, U00 francs. That was successfully

undertaken and by 1958 the incidence of the disease had been reduced to'the

lowest level eves recorded with 229 not i f ied cases.

A11 the available information indicated tha t the disease had become

no more than hypo-endemic: mortality was insignificant; malaria had

disappeared entirely from the towns and persisted only at a very low level

in the wal communities; there had been a complete reversal in the

proporbion of cases caused by the two main vectore - in 1959 4.0%

A,Falciparum and 94.5% A.Vivax, compared with 59% A,Falcba~um and $

A.Vivax in 1935: there had been a decrease in the proportion of poeitive

slides and malarialogical, splenetic and plasma indices had reached a law

level.

Further improvements were expected from the i n t ens i f i ca t i on of

development wmk including an improvement of housing, the development of

the MedJerba valley, i r r iga t ion , some land redistribution and the dis- h .

appearance of nomadism. Systematic tree-planting for the prevention

of soil erosion was expected to modify the effects of the to r ren t i a l

rains which marked the onset of the wet season and might even change the

rainfall pattern altogether . A l l national organ%zations cooperated in the mass campaign8 and were

it not f o r the possibility of epidemic outbreaks which had o c c u w d a a late

as 1954, malaria might be considered a thing of the past. However, &as

~M/R~lW/Prog/pun. 1~ Page 25

of medium 'endemicity still d a t e d , concentrated mo&ly in the.no*h,

Towmds the aoukh the disease became more and more confined to relatively

amall "si& w e l l defined. areas. Although still more progresa could be

aahieved by' the increase in .number '*of $ w e i l l a n u e staff and the opening

of a malaria record f OF each case confirmed by blood test , t'he

continuation of present malaria work would logically lead t o . t h e eradication

of the,diaeasel

The fear of a recmdescepce of the diseaea in a season of

particularly high ranfall was the determining factor in the decision to

proceed .from control to eradicatf on, . a Haever, the G b v e m h t 'did: hot

intend to make that transition so long ae t h e " ~ 1 ~ e r k war contiilu&,

since the health conditions m the scene of the conf l i c t would ehb&er

the success of iny eradication prdar-e Ad the change. which"rdght

result from its settlement might c a l l for different plansr

Meanwhile, a+ pL10-b pro jkt was taking place in Oabun which might

be. expanded to serve as an intamtfonal demonstra$ion project. 'the

authorities were amdoill t o achieve eradication as .om as porvlible in

order to devote more attention to other h e a t h problems which at present

had perforce t o take second place.

Dr PARTW (~raq) expressed hia appreciation of the very

comprehensive repo& and of the de ta i l i n t o which it entered. It

properly' stressed the need f o r great vlgiltlnce a t all stages,

Governments 'would need expert help both a t the administrative and l oca l

implemsntation Levels, No failure could be tolerated* However,

successes had been recorded and apcerncnts s h a d be omc1~kdod

m a n ' governments in the lilegionfor a pooling of experim~e fv

%he benefit of all, Ile was .extremely gyqteful to WHO for assistance I

received.

As could be seen from A n n a 3, much remained to be done and

problem were at111 unsolvedc His Government hoped. t o receive <id

EMfi~lQA/pro in,^. Page 26

f r o m yarious or gmiza.Uonrs to ensure .the success of its eradiaatim work. . ,

The hsal+h au+hax*ities were makbg a conscious ' efforb to avoid'a rout b e

approah .in order ,to m u r e maximum eff icbnw.

Malaria had recently been made not if iable to facil ikab planning. At

t he moment, a cerbin slming in surveillance operw.tiofis was noticed as a

reault of shortage of trained personnel. Recent wnvarsations in Geneva

had stressed the necosaity of increasing the funds on which countries could

c a U for -heir aradioation programmes, fn 1959 the UNICEF Boasd concluded

that assistance to eradication p~oparrpnes wff l be decided on a year t o year

baab, He hoped that this w i l l not mean wimt;hdrawhg maiatance f r o m any

pro$ct that was receiving it. He hoped also that UNICEF would keep aid

t o mlaria eradication at the same level and that h b country would receive

enough to help it to eradicate .the disease,

Ha then ti~anked UNICEF for its asaistancle and expres~led Govemrnent*~

pat i tude to WHO f cpl sending an evaluation team. His Gwerment expected

that SW implementation of the teamls recommendations would bring about

an iqprovement W present methods,

Dr. ZAKI ( ~ u d m ) congratulated me Regiondl Director on t h e exoellent

paper before t h e meeting and Wtanked WHO for i ts work in the Sudan,

EKperience in a. pilot project had s h m t h a t d i e l d r b c o d not be

relied upon s b c e it was b x i c t o domestic anhale and so was refused by

the populaUcaz.

H i s Govermnt reqdred increased a s s l ~ t a n c e since its budget was not - . . . large. In that comectim, he endomed * e remar& of the United Kjngdm

representative and expressed t h e h o p that the United K i n g d o m woulzfirovide

Study of the geography of the Sudan and of its a o c i a l structure had

shown that no project could succeed unLesa n e i a b o u r b g countries mbrked

on similar work at the aame tirne.

rn/ l i~l~~/hog/Min. l/ Page 27

9 QLXjNE (United. ~ingdpm)- point84 out ,that insecticide sp~afing

could never be more .than a partrial 801Utlon to the problem and that . . the

w e l l ~ t ~ e d principles of hygiene, ahoulg not be overlooked, , ,

sf the Sub-Committee for the i r constructive conrments,

The CHAIRMhN invited the Sub-Committee to consider the f oUwing &aft

resolution:

'!MAURM E3U133;CATIOW PROGIZAEYlMES TM THE. E A S m MED1TUBANP;AN FWIa,

The Sub-cormnittee,

Havtng studied the document on Malaria Eradication Programmes in

1 the Eastern Hediterrqean Region, submitted by the Regional Directpr,

NotAng -.with satief . . action t h e efforts mde by mas* , . cauntr+as . of ,the . -

Region in Implementing malar&@ eradication programmes and in coordinatim3

these activities in an endeavour f~ f u l f i l l their partdin gXobal malaria

eradication,

Recognizing that M a r i a not only represents a grave menace to the

h e a t h and economic pxospsrity of countries not yet implementing malaria

eradication progranrme8 but is also a threat to those neighbouring

countrieer which are well advanced in such achemee,

Realizing that sme countr ies which have already launched eradication

campaigns have not yet acccanplished t h e i r objective within the eqected

time and according to plan, becaube their national malaria .eradication-

organizations have nat been provided with wdeqwe adnini~trakive and

fi-mncial requisites md hhe consequent exbemion , , of the progrmes has

involved them and the cooperative agencies in meaeasary eqmditures,

Realiz5ag that some other countries, upon achieySrg favouxable

.results have diminished t h e i r effort and interest a t a t h e when these

should have been intensified t o achieve the .god. of axadlcaiian,

EM/Rc~oA/BxQ~/M~ n. 1 Page 28

Noting the significant recommendations of the Second k g i o n a l

Conference on Malaria badjcation at Addis Ababa which constitute a

synthesis o f the' sxperience of the technical experts and the executives

of mala~ia eradication programes in the Region,

1. EXPRESSES appreciation of the measures taken by the member countries

in developing and executing eradicakion programmes;

2. CONGI1ATUUTE?,Sthekgbnal, Director on the effective rdle that the

technical adv5swy samicea of the World H&h Organization have played

in the achievements so far recorded;

3. URGES member countries to give malarla eradication due priofi ty

in their national health and development plang and ensure united and

coordinated e f f o r t by free exchange of information, by participating in

regional conferences, by effecking inter-country agreements and by

f a c i l i t a t ' h g the work of WOt s Inter-Country Evaluation Team;

4 , DRAWS the attention of Governments to the fundamental importame

of extending to their malaria eradication programmes the continuous

organizatioml and f inancial supporb necessaw for the i r succesef'ul

execution and to meat the criteria fox international assistance$

5 I ENDORSES the recommendat ions of the 3ec ond Regional Conference,- .on

Malaria Eradicationj

6. C A L M upon the Govemmenta and the cooperating agencies concerned,

to implement these recommendations,

D r W I R (lran) suggested t h a t malaria could no longer be

considered tla grave menaceit in the l i g h t of progress achieved and so the

ad jectf ve should be deleted. It was so agreed

I)r* GLmE (United Kingdom) suggested that malaria was a menace only

in sane countries not yet implementing malaria eradication programmes,

A few had already achieved enough control. f o r the problem t o be nm-exist~nt

and a 0 they were not participating in the WHO p r o g r a m .

Dr FARID, Public Health Administrator (Malaria), feared that to

~ 1 0 ~ / ~ r o ~ , ; ~ ; l . Page 29

qualie the statement as the representative of the United Kingdm

suggested would be t o detract fromthe urgency of the matter.

Dr IIHABm ran) added that, if the phrwe ware amended a8

pxoposed, it might be construed to mean that malaria could exist

in a oountry witbout threatening its health and econmlc prorrperity.

He therefore .opposed the United Kingdmjs suggestion,

A (Kuwait) supported the prevAous speakers in oppoaiw

the euggeatian t

Dr Ctm (United Xingdm) withdrew the suggestion.

Decision; The Resolution was adopted as amended, _T

Mental Health in the Eastern Meaterranem Region (EM/Rcl0/4) (Item 10 (b) of tho agenda)

Dr TZGANX EL MAHI, Mental Health Advis~r, speaking at the

invitation of the Chairman, introduced the reporb before the weetirig

and called the Sub-Conmitteels particular attention to the

interdepsndenoe of the concept of mental health and other factors

such a8 social development, rel$gion and e c o n ~ c s aa described in

the opening paragraph. That conferred a particular importance on

team work and any . merit& . heath programme had to cwer the socia& , , . .

economic and ritual aa well as psychiatric aapects of the problem, . , ,

The smphasia had always been a shif t ing one and would contime to . , ,

, -

be so, That applied both to t h e preventive and curative s ides of

health work - the latter eepecially dnce the relation between

the pat ient and his doctors was a highly personal matter where

importednrethods were not always suitable. Succea8 depended upon

close collaboration between mmbers of various branches of the

medical and other professiom and their abili ty to see the patient

in his e n a o n m a t .

Dx BEN SOLTAN3 (Tunisia), speakj.ng a t the invitation of the

C h a w , canmended the &port for the stress it l a id on the

relationship of mental heal th and the environment a t all periods o f

Dl/~~lOA/~rog.Min. 1 Page: 39

history.

After out l ining that histaxy w i t h reference to the salient

personalities and turning t o t he h i s t o r y of mental health work in his

country, he summarieed the progress achieved in &nisiala four years of

independence, It included the improvement of hospital conditions and tho

progressivk abol i t ion of a l l the prison-like aspecte of in te rment and

even t o a considerable extent of interment itself, thanks to progress in

ergotherapy and sociotherapy. He r e f erred in to agr icu l tura l '

act iv i t ies at kknouba hospital , the creation of special workshops and the

elaboration of an organized sociotherapy programme. After reviewing the

graduated ergotherapy and sociotherapy programmes in detail and

describing the stages by which n cure was effected, he outlined t he

Governmentl s efforts to improve the standard of qualification o f existing . ..

mental hea l th personnel and the physical f a c i l i t i e s f o r treatment, The

latter included an interest ing experiment on day-trez.tmont begun in k y

1958 at the B6pital Charles Nicolle. '

It had proved so successful in

using existing fac t ld t i e s in ef fec t ing cures and in promoting the integration

of mental health in general hospi tal work, t h a t the Government intended

t o generalize it,

Improvements in t h e medical treatment of mental i l l -heal th in the

same period included the crsation of two Electro-encephalograph services,

the exbension of insulinotherapy and the generalization of ganglioplegic

treatment.

The t r a i n ing programs provided a number of valuable fellowships

f o r advanced t ra in ing in neuro-psychiatry and fellowships in infanti le

neuro-psychiatry f o r physicians, teachers and school monitors and socia l

workers. The psychiat r ic budget had risen frbn 261,OW dinars in

195647 to 376,000 dinars in 1960 and staff had increased from 256 t o 411

in the same period. The success of the first four years could be judged

EM/%c~OA/P~O~ .Min. 1, Page 31

by the figures f o r the H6pital Razi, In 1959 there were 2993 admissions

and 3Ce2 cases were ascharged and much improved, the diffeqence, be-tween

the &NU figures. repreaen$$ng cases formerly regarded as incurable

recuperated by .the methods to which he had previously referred*

.The country's Andependehce had contributed much both to the

in tcmif ica t ion of mental health work Insofar as it permitted a

liberal approach and to the improvement of the mental health of the

population which no longer l ived in an atmosphere of conf l ic t and

constraint, It had fac i l i ta ted the cooperation between members of the

medical and other professions and between them and the patiopt on which

so much depended;

Mental ill-healkb was, i n fact, a problem of liberty and liberation:

fiberty of Uconductu aiming at sociotherapeutic reeducation to potnote..

initiative and the integration of the par~onality, and .the. Jiberation of

the patient from the conflicts which handicapped hip and set him apart gram

society, thereby hrpedlng the nonnal physchological evolution of hie

personality, The detailqd intensive and supervised ergotherapy an@

socidherapy t o *i,ch he had previously ref erred, enabled the patient t o

exteriddsa and emerge from his conf l ic t s with ,& rastored and

restrmcturized Ego freed from constmint sustained peraonal effort.

That dynamic and progressive approach to treatment o f t h e patient i n

his ot3n cul tura l and h ie to r i ca l background was the one most likely t o

succeed in replacing inhibitioe Qnd maladjustment by emulation in the

development of the personality and in healingcrentivenesa.

b ZAKI (~udnn) welcomed the .Regional .Direct or f s in i t ia t ive in

embarking on work new to the Region in a field where there was much to

be done.

The Sudanese Ministry of Health was increasing the number of mental

health clinics and associating them closely with the medical faculty in

Khartoum in order t o bring homey?he general praotit ionor h i s r e s p ~ i b i l i t i e s

EM/RC~OA/TS~O~ .Mn. 1 Page: 32

W that f ie ld .

A separate administration was to be mnde responsible for mental

health, Lt would deal with the cure of mental disease, research i n t o

the mental health problems of children, adolescents and young adults,

preventive mental health work, training in mental health and mental hedth

in re la t ion t o general. education.

Thf: C H A I M invited the C m i t t e e t o consider the f o l l d n g draft

resolution:

" W T A L HEALTH IN !THE EASTERN ME'DITl3UUWM R E I O N

The Sub-Codt tee ,

Having examined the report on plental Health in the Eastern

~edi terranean ~ e ~ i o n ' submitted by the Regional Direct or,

Cpnsidering that the value of any serv ice is in direct relation t o

i t s canrmunity status and that the effectiveness d mental health

programmes is jeopardized when it is comidered an i n f e r i o r departmbnt

o f medicbe as is the case in certain countries,

Realizing that mental health is inseparable from general medicine and

as such constitutes an integral part of the community md of i t a biological,

soc ia l and economic development,

1, URGES Govermcntsr

(1) to make posi t ive efforts to promote a more effective mental.

h e a t h service within the functional framework of t h e conmnxnity

public health services;

( 2 ) to undertake a programme for the training of personnel at a l l

levels ;

(3) to raise the status of work and of the workers in mental hkd th ;

( 4 ) to moderniae or create new i n s t i t u t ions in order to c q o with

the teohnical and social standards of treatment In a developing

society;

2, fLEQ?JESTS the k g i o n a l Director to assist governments on request,

in all or any of these endeavours.

Dr FARAH (~unis ia) proposed the delet ion of "as is the case in certain

countriesit since it inferred that the problem was less widespread than in

fact it. was,

D r h A B I R (1ran) supported that suggestion.

The RIBZONAL DIRECTOR said that before deciding on khe Tunisian

suggestion the Sub-Camnittee should decide how prevabent was the view

that mental health was an inferior department of medicine. Persomlly,

he felt it was quite common and that mental health should be given greater

emphasis, If the phrase were deleted the point would be lost ,

Dr TIOUiI EL IJULHI, Mental Health Adviser, agreed tha t mental health

was considered an inferior department of medicine in sane countries of the

Region, although in others it was on an equal footing ~ 5 t h other branches.

The phrase had been included to reflect exactly the situation in the Region.

It was less cleer when the phrase was deleted.

Dr F W (~unisia) feared that, ns it stood, the paragraph inferred

t ha t the Sub-Conmittee was passing judgment on certain of t h e Member . .

States represented; t ha t should be avoided*

The HEQIONAL DlRECTCrR agreed that if any such misconstruction were

possible, the phrase should be deleted,

Decision: The resrjlution was adopted with that amendment,

hla-Azar (Visceral. ~eishmaniasis ) in the hastem Moat e m n e a n Region (EM/'Fl~10/6) (Item 10(c) of the agenda)

Dr OMAR, Chief of Qidemiological and dta t i s t i ca l U n i t , speaking

at the invitation of the Chairman, said that leishrnaniasis was common in

most countries of the Region, The document before the meeting contained

a sho r t account of the human parasites as causative agents. Owing to their

morphological similarities t h ~ r e were two school8 of thought: tha t they

~?,@lclQA/Pro~. Min. 1; Page: 34

were a separate species or that they were geographical variants of the

same. The first two c l in i ca l forms ofthe disease had always been ccrmmon

in the kegion, but t he third had been found only recently - i n t he Sudan,

I n connexion with t he maps annexed t o the paper, he informed the

Sub-Committee that as notificztion of leishmaniasis was compulsory only

in five countries, t h e ep id~mio log ica l information on the d is t r ibu t ion

and incidence of {;he disease was not detai led o r statistically rel iable .

It seemed, however, t h a t cutaneous and visceral leishmaniasis were to be

found i n t h e North of Africa and t h a t there was another b e l t across t h e

continent fu r the r t o t h e South. There seemedto be no doubt t h a t there

were t w o main hyper-endemic foc i of viscera l leiskmaniasis - one in the

Sudan and another i n East1 Pakistan.

Both gave r i se t o per iodical epidemic outbreaks the most recent of . - .

which had taken place in 1956 in the Sudan. As a r e s u l t the budanase

Goverment, a s s i s t ed by WHO with t he preliminnxy survey, had intensified

i ts work agains t the disease. It appeared tha tno great progress could

be expected u n t i l more was known about t h e mechanism and environment of

transmission and possible reservoirs of infection. Sandflies appeared

t o be an important potent ia l vector.: .. Recent .research had given new

prominence to an o l d thaory t h a t direct droplet infection was important.

The docwnent went on t o give d e t a i l s about transmission and possible

reservoirs in iisian countries, (page 9 e t seq,) ending with an i n t e r e s t i q

hypothesis about h m n reservoirs. An account of WHO kala-azar survey

i n East of Bcngal (Pakistan) showed t h a t D13T spraying of houses

reduced the phlebotoms population within the sprayed areas almost to

vanishing pa in t and interrupted kala-azar transmisaion. That had been

observed also in Greece and Italy.

Dr PAJlTOGJ (~raq), re fe r r ing to t h e description on>page 9 of the

situation in h i s country, said t h a t oriental sore had always been present

in his country bu t that fewer and fewer new cases were occurring. He a@

hM/~lCu/P1:og. ivdn* 1 Page,: 35

*16h on the improvemerrt- h i - t h e Oriental sore and ai tuatbn achieved by DDT spraying, However, sporadic isolated cases occurred

each year, In t h e c m s e of a p i l o t study, a few cases had been fowld

in. Baghdod, , Before the recent increas,e, $n the number of cases of visceral , , 2 .

leishmaniasis, the average had been ten t o twenty cases per year, a l l

among children, From recent apcrience, It seemed that increases tended

t o take place in the spr ing and to be most noticeable among children

between one and three years of ,age,. . That information was not based on

Dr CHEDLI (Tunisia), speaking at the Chairman? s ind ta t iqn , thanked

'b Omar f o r his report ,and i n t ~ o d u c t f on,

Unlike tuberculosis and malaria, kala-azar which was hypo-endemic . .

'in Tunisia, had not been the subject of special control. campaigns although . .

.cases had been recorded and observed between 1907 and 1938 and from 1956

onwards.

.The document before the meeting made no mention of a fourth form of

Leishmaniasis - the generalized dermal infection found in South America

and rnore,recently in Ethiopia - which was not as yet morphologically

well-defined.

At present, the total number of cases of kala-azar diagnosed in

Tunisia was 182. In 1957 the total number of cases has been 169. The

thirteen new cases recorded since then were f r om t w o hospitals in funis

and one in zoussc. As the Pasteur Institute could not cwer a l l Tunis

hospitals a number of caaes had no doubt escaped record, All the new

cases were children between the ages of 14 months and 8 years ,most being

in the age group 1-3 gears, Twelve were Tunksian l-ioslms and the

t enth thiry was Italian. Ten came from Tunis, two from Cap Bon and 1 from Sousse.

2.40 of the total of 102 recorded cases came from T d s and almost a11 from

the north, Boys seemed more vulnerable than girls and childrm between

EM/Rc~OA/PK~~. fin, 1. Page: 36

more so on& - an3 ' thrk6 ' of oge/than adul t s , : although adult cases had been

seen,

Such statistics as were available showed a curious reversal of the

me-1938 trends after 1956. Wing the flrst period of observation,

I ta l ian cases had heavily outnumbered those among Tunisian iJ16~lms

and Jews, During the aecond, there had been a rapid and continuing

increase in the number of casee among the Tunisian Mohammedans and a

spectacular decrease among the Italians, Ch, Nicolle had attributed the .. , " .. ,

, - 1 . . . ..

predominance of Italians to the fact .that they .often kept dogs which they I .

had brought with them from I t a l y and wbich, owing to t h e change of climate,

were pal..l;icularly susceptible to uanine l e i s h a n i a s i s , and acted as

rsservoirs of the disease, However, t h e reversal of the trend did not

seem to be accompanied by aw increase in the dog population among

Tunisians, although the progressive acquirement of immunity by the canine

population of I tal ian or ig in might account for the decline of the number

of cases among Italians.

There seemed to have been no increase i n tho overall incidence of

the disease since records had been kept,

The Govcxnmcntts action had recently been directed to early

diagnosis which had been kacil i tated by the health education of the

public and the increase in the number of chi ld clinics. Malaria work

would reduce the number of caseEs of enlarged spleen and make the

diagnosis of l e i s h a n i a s i s caster, Tho dmtmct ion of stray dogs in

the course of rabies work could also be expected to lead to a decrease,

Future work could usefully include house spraying, t o destrw the sandfu

since it had proved i t s effectiveness in Pakistan, Greece and Ttaly.

In addi t ion to continuing prophylactic mearsures, his Government intended

to continue recording cases in the hope of f i l l i n g in some of the gaps

in epidemiolcgical knowledge. The general practit ioner had a

contribution t o make and his observations might prove decisive*

m i / ~ c l ~ ~ / P r v ~ ,M,~L. X, Page: 37

To ensure that they were,known, notif icat ion of the disease should be

made compulsory wherever t h a t was not y e t the case,

WHO should assist all countries where lack of bowledge prevented

progress, to develop epidemiological surveys the results of which would

be of value to all,

D r EmDIAN ran) congratulated the Hegioml Office on an

excellent report.

Noting the paragraph about h i s country on page 9 , he explained that

visceral leishmaniasls was a clinical curiosity there and the incidence

of the cutaneous form of the diaease was decreasing constantly.

Dr ZAKX (Sudan) welcmed the report which gave a complete picture

of the s i tuat ion.

Leishmaniasis was' endemic. in the h d a n and there had been an

epidendc of the viscera2 fom of the disease in 1956-57, in which pbriod

alone 7436 cases had been diagnosed, Mortality had been h Q h early In and this wtm

the epidemic (6%) because so much depended on early treatmentymade

d i f f i c u l t by the season and the absence of other infectrons such as

malaria. He then outlined the treatment given.

In that emergency, his Government had appealed to the WHO and the

United States Government for assistance. As a result, h Seal of the I L

United sates Naval Medical hesearch Unit Ho.3 Zn C a b o had a Z t e d *e

infected area and a centre for the study of the disease was being b u i l t

i n ~ e Upper Nile province. It was expected t o be completed, staffed and

in operation i n the autumn of the current year, It would study among . I .

other subjects the mechanism of transmission with particular reference

to the possible existence of a human reservoir* Nutritional studies

would also be made,

In conclusion, he thanked WHO and 3h. Seal f o r the i r assistance,

Dr s&,, h e c t o r of Itesearch Activi t ies of the United States Naval

Medical &search Unit Eo.3, kb~, ~ p o n k i n g at . t o h~ibt3.m of tho &&3WXl

aaid that in t he course of a tour of thc Sudan in 1959 a t the invi tat ion

of the Sudanese Government, he and the entomologist acconrpawing hjm had

become intereeted in the d-lsease and convinced of the need for and

fruitfulness of research.

A point the docutlent did n o t make was that a measure of successful

control had been reported by e l i d n z t i o n in some countries of the dog

population and by residual spraying against Phlebotamus in the home, or

ac,riSl spraying around towns. The incidence of oriental sore could be

reduced c~nsidcrably in that way but there had been few good epidemiological

studies showing that t rue kala-azar could be reduced.

Visceral leishaniasis was a dif f went matter. the problem as it

occurred in the &dnn and Kenya was apparently different from that in

other parts of the world. Dogs did not seem to be n reservoir of

infect3.0n and no other reservoir hnd been identified, The sandfly

probably continued. to be t he most important vector in the Sudan though

there might be others. l'he disease in the bhdan wae charactcrised by

resistance t o antimony compounds and a 15-day course of pentostam cured

not more than 5W of cases althuugh the percentage of cures was much

higher in India. The drug was a l s o inadequate in Kenya, There were so

many diflelrenc~s betwc:en the disease as it appeared in the budan and

Kenya and as it occurred in the other countries t h a t thore semed good recsor

t o suspect c different s t r a in of leishmaniasis, The apparent noed for

research to fSnd points of a t t ack on that different problem was such t h a t

the United Skates Nzval Nedical hesearch Unit No.3 had offered t o join

Fiith the Sudanese Gwcrnment to f ind solutions,

At present t h e m seemed t o be little hope of the .development of' a

new and superior therapeutic ngent in the irmediate future. A

prelilrdnary survey in t h e spring of the current year had confirmed the

obsefia6ions d~scr ibed by the represenkeifiive of. the audan and others,

The possibi l i ty of these being a rodent reservoir waa being investigated

and culture tscr;wdques would be studi.66 ahqrtly. P.Pclpatnsi had been during the past year

th; ordy %peoies 'found to bite man/although P.Clydei and others had been

previously observed*

Kirkrs observations had suggested that the asease was conkraotsd

in the bush rather than in towns. or eyen villages so that spraying might

not give the results which the experience reported in the document d g h t

su&est. The possibility of a hwnan reservoir was being borne in mind

with transmission either direc t ar thrqugh an intemedin~y ~ U c h might be

the aandfly,

He then paid t r i b u t e to the heroic efforts of the Sudanese

Government in case-f inding and trectmait which had succeeded in bringing

about a decrease in the number of new cases, The new Centre would

thoroiighly explore the rnechanisq of transmission, the reservoir problem,

caa&finding 'and therapeutic methods suitable for mass cempaigns,, . , and

the immunological background gf the disease-

' Br W, , Chief of Epf demiolog~cal , , npd Statistical Services, pointed

out that the type. of' Leiahmaniasis mentioned by the representative of

WsZa.rjaa referred to in document, E M / R C Z ~ / ~ in section I, first

+pa'ra'graph, a ~ b ~ p e r a g ~ a p h , . 2!,,md in ae-ction V. He agreed with t h e

Tunisian represent atiiel s kLewd o n - conrpu~sory notif icat$on o f :t& . ., disease

and suggested th9t a provlaion :to .that effect might be included in the

draft resolution,

The C H A L W drew the camittee's attention to the fo1lmKhg

draft resolution:

The Sub-Commj ttee,

Noting with intereat tho r cport on Kala-aear (~iaceral ~eishmaniasis 1

submitted by the Regional Erec to r ,

Recogni~ing that the various forms of LeishmanZasis are endemic in

'document ~1*~10/6

EMficl~/~/~rog. M h . l Page: 40

11

maw parts of the* Eastern Meatemanean fcegi on,

No%% that in spit'e of budies alreaw undertaken the questions of

tmmrdasion of the disease and the animal reservoir of infection st i l l

remain t o be ~ 0 1 ~ e d j

REQUESTS the Regional Director t o follow-up the investigations

recently carried out in the Region and on request t o give assistance to

countries in the control ~f the asease , in carrying out survey&, dr under-

taking research i n t o the problem. 11

The hlzlif W L DlRECTOFi suggested tha t the fo l lowing operative

paragraph should be inserted before the existing operative paragraph:

' RECOMMENDS the addition of leishmaniasis to the list of notif iable

diseases in countries where regulations to t h i s e f f e c t do not e x i s t . "

Dr GLYWME (Unites Kingdom) pbintcd ou t that in countries such as Aden

wherk the disease was very rare, such a regulation was not necessary;

He therefore suggested that the words "where appropriateu should be

inserted at a suitable point in $he Regj-onal Dfrectort s amendment.

The Rl?GION;AL DIRECTOR agreed to that suggestion.

The amendment suggested by the Regional Director was adopted.

The draft resolution bn kala-azar (visceral leishmaniasls) in t h e - Eastern Mediterransan,Hegion, as amended, was adopted.

PUBLIC Hl3UT.H ROUE IN THE DXSPOGAL OF RADIO-ACTIVE WASTE (Item 10(d) of the agenda)

Dr EL HALAFJANI, Deputy Regional Director, introduced the report on

the public health role in the disposal of radio-active waste ( E M / R c ~ o / ~ ) .

The document was designed for public health acbn in i~ t~a t~PB rather than . ..

specialiats and dealt with two main subjects, namely, the importance of

public health work in the .- field and the dangers arising from the developmen

of atomic energy, Not aU. countries in the b g i o n had atomic energy

progrmesas yet but it was to be expected that they w a d enter the f i e l d

in time. All possible safeguards agzxi nst exposure t o radiation must,

EN/RCIQA/&O~. Min. 1 Page: 4 l

theref ore, be investigated4

Environmental contalrdmtion could come frch vhribus sources,

including ind&try, mining, reaotois, fuel processing and so on. Th.

atmosphere could he contaminated not only by tests but a lso by fumes f rm

industxial plants, reacto~s, etc. Contamination could occur under normal

conditions or as the result of an accident. In either case, the public

health administration should have a full knowledge of t h e subject, since

it was the authority which would have t o deal with the si tuat ion,

Valuable howledge had been obtained as the result of accidents in developed

countries, such as that a t Windscale.

The report describedthe closed and open f o m of radio-active

material used in hospitals and laboratories and the methods of disposing

of them. Isotopes were widely used in medicine, agriculture, iiidustry

and nutrition, so t ha t many workera were Liable to be exposed t o radiation. , \

iPhe public health a h i n i e t r a t ~ o n should theref ore supervise the use o f

i-satopes, keeping recor& of act iv i t ies involving them and of the .disposal

of waste. The subject had so far been the province of scientists, but it

was time for public health adminiatrationsto assume respomibility,

WHO had produced a report on ,Methods of Radio-Chdcal A n a l y s i s which

had been found very ueeful by laboratories, The IAEA Laboratory in Vienna

analyzed fsod.and other substance@ f o r e t roi~t iwn and other isotopes,

Its experf encc had been of help to mav other laboratories.

Disposal of radio-active waste by b u y i n g had the disadvantage that

it' d g h t be uncovered in the course of agricultura2 activities. l'here

was also a danger of exposure in post-mortems, c r ~ t i o n and embalming of

corps&s, h p o s a l of waste in the aea had been deal t with a t a special

conference; the subject was very wide and waa merely outlined in the r fport .

The report dealt with the importance of weather stat ions in detecting

conkmination of the atmosphere by tests, industry w accidents.

Final ly he drew the at tent ion of the C o d t t e e to a pamphlet- (Safe

EM/RC~OA/P~O~ .Wn. 1 Page: 42

Handling of ~adio-lsotopea) published by the IAEA, and t o the

recormnendatisns of the International Commission f o r hadloiogical

Protection, a brief extract from which appeared in Annex I1 of the Report.

Dr Z A K I (Sudan) sa id that the role of public health in the

disposal of radioactive wastes was a subject of v i t a l importance.

Although the atomic industry in the fiegion was not as y e t far advanced,

governments were interested in bui lhng reactors, in set t ing up radio-

isotope units and in using radiation for the treatment of cancer,

Moreover, radio-active waste was already found in the bgion , and the

amount would increase as industry turned more and more t o nuclear power.

Tt was2essentia1 t h a t countries should take immediate steps f o r dealim

with present and future problems connected with radio-active wastes,

especially in view of its effect on food and water* He was glad t o note

from document E M / ~ c ~ o / ~ $hat W O was playing an important par t by such

methods as organizing study groups to consider the problems of radio-

active waste. In his view, a special u n i t should be set up to examine

the problm as a whoa@.

Mr ROBERTS (~nternational Atomic: Xnesgy ~ ~ e n c ~ ) , speaking at t h e

invitat ion of t he Chairman, said that he wished to express the bes t wishes

of the Urector-General of his Opganization for t he success of the

Sub-Committeeb meeting and his appreciation of the invitation to attend it,

Document EM/RclO/7 seemed to him a very comprehensive description of

t h e role of publ ic health in radiation protection. H i s Organization

greatly appreciated the work tha t was being done by WHO in t h a t field,

with a special reference t o radio-active waste disposal, There was no

doubt that radiation protection could only be f u l l y effective with t h e

cooperation of public health author i t i es , who must, among other things,

have aavttal say in the establishment of maximum permissible concentrations.

In order tha t the Sub-Committee might be f u l l y informed of the efforts

being made t o enable countries to u t i l i z e the benefits of nuclear energy

~ / R c l a ~ / P r o g . Min. J PBge: 43

energy In safety, he gave a brief account of activit ies recently

undertaken br sponsored by the International Atomic Energy Agency fxl

connection with radioactive waste disposal.

The CHAIRMAN, after thanking the hepresentative of the International

A t d c Energy Agency fo r his statment, proposed that the fo l lowig draft

resolution be adopted:

Having considered with interest the doom? on the Public Health Role in the disposal of Radio-active Waste submitted by the hegi onal Uirector,

Recalling Resolution EN/h~9/..8. adopted by the Bsgional C w t t e e of the Eastern Mediterranean at its 1959 Session oomerning I o d ~ i w RadLation in Medicine and Public Health,

Noting resolution E325,~63 of the hecutive Board and the subsequent Ileaolution WAl3.56 of the Thirteenth World Health Assembly on "I~adiation Health, including protection of %kind from Ionizing Radiation Haaa;rds, whatever their source",

Considering, that the use of Radioactive Isotopes for research, diagnosis and therapy has increased in the Region and plans are underway f o r greater activ:ity in the f i e l d of radiology,

hJoting that problems are arising or w i l l arise as a consequence of further use of atomic industr;y and. the resulting radioactive waste disposal and environmental contamination, especially in comexion with water and foodstuffs , particularly milk,

Considering .that the f inal reeponsibility for the protectton of the public against the health hazards of radiation rests with the public health administrations ,

1, URGES States kmbers of the hegional Committee to organize within thei r Ministry of Health a special deparwent t o deal particularly with the control of radiation in order to ensure that it is w 3 W a the range of permissible doses, and to undertake inspection of the various sources of radialion in the country;

2. REQUESTS the Regional Director to assist Governments in their effort8 in this regard particularly in supplying expert advice on protection from radiation hazards including the effective disposal of radioactive wastes, and in awarding fellowships f o r trainillg in the f i e ld ;

3 EMPHASIZES the need for close contact to be maintained with IAEA, UfiSCM and other agencies or organizations concerned with the problem of radiation.

It was so aareed.

he meeting rose at 4.10'bem+

EM/Rc 1 0/7-