May 23, 1995, UCLA (Notes by Jim Stewart, SCCED)
Introduction by Dean A. A. Afifi, Dean of the UCLA School of Public Health: International health is an oxymoron, there really is only global health.
Background of WHO by Milton Roemer, M.D., MPH: The earliest cross-national work for health was in the 16th century when Portugal provided health services for Portuguese settlers in China. The British East India company provided services to British nationals in the 1800s, but by the 1890s had learned that their health was influenced by the health of the local people and so it developed the Indian Medical Services. In addition, there was much work by religious missionaries, the most famous of which was Dr. Schweitzer in Africa. The Roman Catholic church did a lot in Latin America. In 1913 the Rockefeller Foundation established its International Health Division. During World War I public health services expanded in many countries.
Although social security started in Chile in 1924, the Ministries of Health started in South America in 1940s. In China, the Peking Union Medical College started in 1914, which was the pilot for health services throughout China.
International coordinated efforts began with the first International Sanitary Conference in 1851 to develop policies for quarantine for contagious diseases. But it was not until 1892, at the seventh International Sanitary Conference that an international agreement on quarantine relative to cholera was finally adopted.
In the Americas, the Pan American Sanitary Bureau was started in the 1800s. In 1948 it became the Pan American Health Organization and the regional office for WHO.
After World War I, the League of Nations Health Organization established a malaria Commission and a Cancer Commission, but it all ended when the League collapsed in 1939. In 1946, an International Health Conference led to the creation of WHO at the Health Conference in 1948. WHO is affiliated with but not under the UN.
There are other international organizations that relate to health, such as UNICEF, the International Refugee Organization, UNIRRA, etc.
In 1946, President Truman set up the Point 4 Program for foreign aid, which included health. By the 1980s, there had been a total of $300 billion spent on foreign aid, but only $3 billion for health. About $1 billion was spent through WHO, the rest by US and European governments. Until the 1970s, the money was spent mainly on population control, then in the 1970s and 1980s, the interest of the U.S. shifted to primary health care.
The WHO Constitution has a preamble stating nine principles of health. Number one is: "Health is a state of complete physical, mental and social well-being, and not simply the absence of disease." An international conference in the 1980s declared the objectives have not been reached, which resulted in the "Declaration of Alma Atta," which defined the principles of world health, including the eight elements that constitute primary health care, prevention and treatment of common diseases.
Fighting Infections by Ralph R. Frerichs, Chair of Dept. of Epidemiology, DVM, Dr. PH.: I want to talk about five example health problems:
1. Smallpox: In 1960 WHO became committed to the eradication of smallpox, using a vaccine discovered 107 years earlier. WHO got all the countries together to cooperate in the eradication. The last case of smallpox occurred in Oct. 1977 in Somalia, when Ali Malin, drove 0.5 mile in a vehicle with 2 small children asking for directions to an isolation camp. He developed smallpox, and exposed 161 persons, but none got the disease, and the eradication was complete. Now the virus exists only in labs in Russia and in Atlanta.
2. Polio: We are now close to the eradication of polio. In 1988, when WHO resolved to eradicate polio, there were 35,000 cases, now there are only 6,000 cases. They are using both the Salk vaccine and the oral vaccine. The Chinese have the world's record of vaccinating 83 million children in 2 days in 1982 and 1983. The target is eradication by the year 2000.
3. Tuberculosis: TB kills 3 million a year, with 8 million new cases a year. The problem is many strains have developed resistance to antibiotics when they are not taken to completion. Now we are moving to "directly observed treatment," in which medical personnel watch the patients take the medication.
4. Ebola: The movie "Outbreak" is similar to the situation in Zaire, which I have been following on Internet, where WHO publishes updates every few days. There are now 171 cases and 101 deaths. This outbreak started in December 1994 in rural Zaire. It was spread in a hospital with non-sterile conditions, where a tradition of close contact with the dead is a problem. The virus is similar to one in 1976-77, so there must be an animal reservoir to harbor the virus. It is a maladaptive virus because it kills the host quickly and quickly dies out. However, if it mutates and becomes adaptive, it could be a big problem.
5. HIV: There are 18 million cases worldwide. It is a very adaptive virus and can remain in individuals for up to ten years. WHO has not been successful in controlling it. Starting in December 1995 they will move the office for HIV activities into the UN to involve many different UN agencies in this effort.
Assuring Good Food by Gail Harrison, Ph.D., Chair of Dept. of Community Health Sciences: Malnutrition is a continuing battle being worked on by WHO, FAO, UNICEF, Refugee organizations, etc. In the 1970s the "Green Revolution" increased the food supply. Currently, the global supply is adequate to meet the caloric needs of the world's population. If everyone adopted a vegetarian diet, and if it were distributed equitably, we have enough calories to feed 115% of the current population, but we would need additional food or supplements to meet needs for micronutrients, such as vitamin A, etc. However, if the world got 15% of its calories from animal products (which is modest by U.S. standards), we could meet only 77% of world's current food needs.
Food self-sufficiency is decreasing. Now 99 countries have to import food. Since 1965 some 75 countries have declined in self-sufficiency, with only 45 as stable or increasing self-sufficiency. It is clear there is need for interdependence among nations to guarantee food security for all. The average number of calories available to meet dietary needs is below minimum requirements in 48 countries containing 200 million people, 100 million are in Pakistan, most of the rest are in Africa. Also FAO emergency food operations are increasing. There are 20 million international refugees, in 10 countries they exceed 5% of population. Plus there are another 20 million people who are internal refugees. Hunger is coming to Europe: Armenia is looking bad, Bosnia is not good.
Another problem is food poverty, when people do not have enough money to buy food. The FAO and World Bank both estimate an increase in food poverty since 1975. In the U.S. 13% are food poor, and current Congressional proposals will increase that.
Another issue is food deprivation. Some 46% of the world's children are growth stunted from malnutrition. The FAO goal is to eliminate vitamin A deficiency. Some 124 million children are vitamin A deficient, mainly in Indonesia and the Philippines.
The bottom line is that the margin of the world food supply is currently very slim.
Training Health Personnel by Glenn Melnick, Ph.D., Professor of Health Services: There is a growing demand for trained health personnel. Economic development stimulates the demand for health services. After basic infrastructure development is accomplished, the emphasis shifts to social services including health services. With development there is a change in the mix of services as the population growth rate declines. The need for children's services declines and need for serving the aging increases.
Because health reform is happening in other countries, such as the Philippines and Taiwan which have instituted national health insurance, there great need for both providers and managers of health care. The question is who will train the people needed?
There is a need for U.S. personnel to go overseas to train others, because there are few schools of Public Health in other countries. Financing is a big need, but the World Bank is providing less funding, and USAID is going to be cut by the current Congress. Previously, USAID has been funding many people from abroad to come to school in the U.S.
The Future by Osman Galal, Director of the International Health Program, M.D., Ph.D.: Using biostatistics is very important to see the trends. The major impacts of WHO since the Alma Atta conference have been on the primary health care system with the goal of achieving "Health for All by the Year 2000." The approach of primary health care has been to bypass the clinical professions and go directly to community health, family planning, and other services outside the clinical professions.
WHO has brought together the countries on global health issues. There is increasing communication among countries, and some ideas from developing countries can help developed countries. Emphasis has been on the immunization of children, on family planning, and on oral rehydration. The latter has reduced infant mortality rate by 50%.
However, so far the programs have not achieved the WHO goals and health for all by the year 2000 will be difficult to achieve in the next five years.
There has been a decline in mortality rates, but a rise in morbidity (more sickness than before). In the past people were affected by infectious diseases and died quickly, but now there is a shift to chronic diseases. There has been a shift in the attitude of individuals in terms of life styles, such as less smoking, more exercise, and better nutrition, but there is a rise of chronic diseases including cancer, which is abetted by inappropriate diets.
We are linking oral rehydration (against diarrhea), immunization, and family planning in one program called the child survival program, which is crucial. The question is whether the old strategy of health programs to combat infectious diseases is appropriate for the new era of morbidity. WHO is shifting emphasis from primary health care to morbidity issues.
Questions and Answers
Q: Does the $3 billion in health aid include food?
A: That $3 billion includes nutrition education, but not the provision of food.
Q: Health care requires political stability, so how do we keep population increases from over-running the food supply and the need for health services?
A: We must stress health education, change nutrition, reduce smoking, etc. We need to do some arm twisting to change behavior, especially regarding family planning attitudes. We should start educating children very early in life.
A: Roemer: The population issue almost split WHO, because the Roman Catholic countries threatened to leave WHO if it did family planning, so it could only do research. Population is an issue for the UN but not WHO, and this is unfortunate.
Q: With the great need for Health for All by the Year 2000 and Education for All by the Year 2000, the question is how do we finance the UN and all the agencies. How can we create more funds?
A: Galal: We have worked on health education for communities, but not for the authorities that have the money and determine the policy. We need to target the top levels of government.
A: Afifi: The value of the UN has been primarily as an escape valve to avoid armed conflict between the two super powers. It was started with that political objective in mind. So as long as there were super powers, the UN was seen as necessary, but today, the US is being influenced by shortsighted politicians, such as Gengrich, who see no need for the UN. Nonetheless, I believe there are enough people that see the good reasons for the UN. Educating our state and national representatives is crucial. We must put the pressure on Congress, as we did when we campaigned to keep federal funding for public broadcasting.
Q. The Ebola virus has scared a lot of people, yet Zaire will give you a hard time to get a visa to get in.
A. WHO can provide the umbrella for US and other personnel to go and work on the issue. This shows how you need international organizations like WHO.