The world's biggest killer and the greatest cause of ill-health and
suffering across the globe is listed almost at the end of the International
Classification of Diseases. It is given the code Z59.5 - extreme poverty.

Poverty is the main reason why babies are not vaccinated, why clean
water and sanitation are not provided, why curative drugs and other
treatments are unavailable and why mothers die in childbirth. It is the
underlying cause of reduced life expectancy, handicap, disability and
starvation. Poverty is amajor contributor to mental illness, stress,
suicide, family disintegration and substance abuse. Every year in the
developing world 12.2 million children under 5 years die, most of them
from causes which could be prevented for just a few US cents per child.
They die largely because of world indifference, but most of all they die
because they are poor.

In the time it takes to read this sentence, somewhere in the world a baby
has died it its mother s arms. For that mother, the message that her
neighbour's infant will live is no consolation. It does not stem her grief
to know that 8 out of 10 children in the world have been vaccinated against
the five major killer diseases of childhood, or that globally since 1980
infant mortality has fallen by 25%, while overall life expectancy has
increased by more than 4 years, to about 65 years.

Beneath the heartening facts about decreased mortality and increasing
life expectancy, and many other undoubted health advances, lie
unacceptable disparities in health. The gaps between rich and poor,
between onepopulation group and another, between ages and between
the sexes, are widening. For most people in the world today every step
of life, from infancy to old age, is taken under the twin shadows of
poverty and inequity, and under the double burden of suffering and
disease.

For many, the prospect of longer life may seem more like a punishment
than a gift. Yet by the end of the century we could be living in a world
without poliomyelitis, a world without new cases of leprosy, a world
without deaths from neonatal tetanus and measles. But today the money
that some developing countries have to spend per person on health care
over an entire year is just US $4 - less than the amount of small change
carried in the pockets and purses of many people in developed countries.

A person in one of the least developed countries in the world has a life
expectancy of 43 years according to 1993 calculations. A person in one of
the most developed countries has a life expectancy of 78 - a difference of
more than a third of a century. This means a rich, healthy man can live
twice as long as a poor, sick man.

That inequity alone should stir the conscience of the world - but in
some ofthe poorest countries the life expectancy picture is getting
worse. In five countries life expectancy at birth is expected to
decrease by the year 2000, whereas everywhere else it is increasing. In
the richest countries life expectancy in the year 2000 will reach 79
years. In some of the poorest it will go backwards to 42 years. Thus
the gap continues to widen between rich and poor, and by the year 2000
at least 45 countries are expected to have alife expectancy at birth of
under 60 years.

In the space of a day passengers flying from Japan to Uganda leave the
country with the world s highest life expectancy - almost 79 years - and
land in one with the world s lowest - barely 42 years. A day away by plane,
but half a lifetime s difference on the ground. A flight between France and
Côte d'Ivoire takes only a few hours, but it spans almost 26 years of life
expectancy. A short air trip between Florida in the USA and Haiti
represents a life expectancy gap of over 19 years.

The purpose of the report is to highlight such inequities and to tackle the
wider question: what are the global health priorities? It also tries to
answer other crucially important questions. Which are the major diseases,
the major causes of death, handicap, disability and diminution of the
quality of life? Which conditions cause most misery, although they may
not be fatal? Which countries, or communities within countries, have the
greatest health needs? Where should health resources be targeted?

The report, for the first time, has attempted to examine the burden of
ill-health not just by disease, but also by age, as the impact of illness
differs across the age spectrum. Where possible, the analysis of health
status has been carried out for infants and children, adolescents, adults
and the elderly. On the basis of the data available and considered to be
reasonably reliable, ten leading causes of death, illness and disability
have been identified. There is also an explanation of what WHO is doing to
bridge the gaps in health, an attempt to assess health trends in the coming
years, and an effort to chart a health future for mankind - a future in
which a baby lives, not dies, in its mother's arms.

The number of children under 5 years who died in 1993 - more than 12.2
million - equals the entire populations of Norway and Sweden combined. Of
such deaths in the developing world, the great majority could have been
avoided if those countries enjoyed the same health and social conditions as
the world s most developed nations. The gap between the developed and
the developing world in terms of infant and child survival is one of the
starkest examples of health inequity.

The estimated global figure for mortality among children under 5 years in
1993 was 87 per 1 000 live births, an encouraging fall from rates of 215
during the period 1950-1955 and of 115 in 1980. Yet in parts of the
developed world only 6 out of 1 000 liveborns die before reaching age 5,
whereas in 16 of the least developed countries the rate is over 200 per 1
000, and in one country it is 320 per 1 000.

Infant mortality - deaths of children under 1 year - varies from 4.8 per 1
000 live births to 161 - a 33-fold difference. The gap in infant mortality
between developed and developing world narrowed by 50% during the years
1960-1993, from 113 to 54 per 1 000 live births. But at the same time
the gap widened between least developed and developing countries.

Malnutrition contributes substantially to childhood disease and death but
often goes unrecognized as such. In 1990 more than 30% of the world s
children under 5 years were underweight for their age. As many as 43% of
children in the developing world - 230 million - have low height for their
age. Micronutrient malnutrition is estimated to affect at least 2 billion
people of all ages, but children are particularly vulnerable. As a result of
iodine deficiency - a public health problem in 118 countries - at least 30
000 babies are stillborn each year and over 120 000 are born mentally
retarded, physically stunted, deaf-mute or paralysed. A quarter of all
children under age 5 in developing countries are at risk of vitamin A
deficiency.

There have been improvements in child health, and 1993 saw the number of
children dying from vaccine-preventable diseases reduced by 1.3 million
compared to 1985 - equal to the population of Trinidad and Tobago.
Nevertheless, around 2.4 million children under 5 years are still dying
every year from such diseases, particularly measles, neonatal tetanus,
tuberculosis, pertussis, poliomyelitis and diphtheria. There are also
worrying signs that recent immunization gains are being eroded or even
reversed by economic and social conditions.

Every year in the developing world acute respiratory infections,
particularly pneumonia, kill more than 4 million children under 5 years -
one death every 8 seconds - and are a leading cause of disability. They
account for 30-50% of visits by children to health facilities everywhere.
Significant reductions in mortality could be achieved by treating the
underlying bacterial infections with low-cost antibiotics for a few days.

Diarrhoeal diseases, resulting from unsafe water and poor sanitation coupled
with poor food-handling practices, are responsible for a further 3 million
deaths a year among children under age 5 in the developing world - one every
10 seconds - and are a graphic example of the deadly synergy of poverty and
lack of knowledge. Worldwide there are an estimated 1.8 billion episodes of
childhood diarrhoea annually. Many of the deaths from diarrhoea could be
prevented by using oral rehydration salts, which cost just US $0.07 on
average.

Across the world some 2.3 billion people, about 40% of the total population,
are aged under 20. Although teenagers and young adults are generally
healthy, they are among the most vulnerable in terms of the diseases of
society - poverty, exploitation, ignorance and risky behaviour. In
squandering the health of its young, the world squanders its tomorrows. The
behaviour patterns established in adolescence, highly influenced by the
adult world, are of immense importance to an individual's life span and to
public health as a whole.

In many countries health services are not meeting adolescent needs,
and there are concerns that education, training and jobs for the young
are inadequate. Education is a vital, although often unrecognized,
contributor to the well-being and sensible fertility practices of young
people, because schooling is linked with health status and pregnancy rates. A
blackboard and piece of chalk can be as influential as antibiotics and
contraceptives in protecting health. Improving the education of adolescents
in general, and girls in particular, is one of the most effective ways to
promote equity, enhance development and protect health for all.

The desire for sex and a fulfilling relationship are powerful driving forces
for most young people, who at the same time are under pressure to engage in
sexual relationships too early. Yet many young people are denied even basic
knowledge about their own bodies or the means to protect themselves from
unwanted pregnancy and sexually transmitted diseases (STDs). These diseases
are most frequent in younger sexually active people, and appear to be
increasing worldwide. The highest rates for notifiable STDs are generally
seen in the 20-24 age group, followed by those aged 15-19 and 25-29. In
nearly all parts of the world the peak age of infection is lower in girls
than in boys.

At the same time HIV and AIDS are having a devastating effect on young
people. In many countries in the developing world, up to two-thirds of all
new HIV infections are among people aged 15-24. Overall it is estimated that
half the global HIV infections have been in people under 25 years - with 60%
of infections of females occurring by the age of 20. Thus the hopes and
lives of a generation, the breadwinners, providers and parents of the
future, are in jeopardy. Many of the most talented and industrious citizens,
who could build a better world and shape the destinies of the countries they
live in, face tragically early death as a result of HIV infection.

Other health dangers facing adolescents include tobacco, alcohol and other
drug misuse, their exploitation as cheap and often illegal labour, and the
worrying growth in the numbers of street children. Recent estimates suggest
there may be as many as 100 million street children, at high risk of
malnutrition, infectious diseases, STDs including HIV/AIDS, and criminal and
sexual exploitation. The rise in accidents, violence and suicides involving
young people in many parts of the world is a cause for deep concern.

Globally about 51 million people of all ages died in 1993, about
three-quarters of them adults. Some 39 million deaths took place in the
developing world and about 12 million in the developed. Poor countries had
three times more deaths than rich ones.

Communicable diseases such as tuberculosis and respiratory infections as
well as maternal, perinatal and neonatal conditions account for about 20
million, or about 40%, of the 51 million global deaths; and 99% of these
occur in the developing world.

Noncommunicable diseases such as cancer and heart disease account for about
19 million deaths, or 36% of the global total, divided more or less equally
between the developing and the developed world. The great majority of such
deaths are among adults.

External causes such as accidents and violence account for about 4 million
deaths, or some 8% of the total, again mostly among adults. Developing
countries have nearly four times the number of deaths from these causes as
the developed world. Other and unknown causes account for the
remaining 16% of deaths worldwide.

Of the 20 million deaths due to communicable diseases more than 16 million,
or about 80%, are due to infectious and parasitic diseases. Tuberculosis
kills about 3 million people, malaria around 2 million and hepatitis B
possibly 1 million.

Among the major communicable diseases, tuberculosis was responsible for more
than 5% of the global total of deaths - over 7 000 a day - and it is
estimated that there will be 8.8 million new cases in 1995 - equal to more
than 1 000 new cases every hour of every day. Drug treatment, in most cases
costing as little as US $13-30 per person for a six-month course, can cure
people; but providing the drugs to those who need them, and ensuring that
patients take them for the required period, is a major public health
challenge.

Meanwhile the lethal relationship of tuberculosis with HIV is making the
death toll many times worse. During the next 10 years in Asia alone it is
estimated that tuberculosis and AIDS together will kill more people than the
entire populations of the cities of Singapore, Beijing, Yokohama and
Tokyo combined.

Malaria, directly or in association with acute respiratory infections and
anaemia, causes around 2 million deaths a year, the vast majority among
young children, and some 400 million cases annually. Globally more than 2
billion people are threatened. The estimated direct and indirect cost of the
disease in Africa alone is expected to reach US $1.8 billion by 1995.

Cholera has become endemic in many countries in Africa, Asia and Latin
America. In 1993 there were 377 000 new cases reported and only 6 800
deaths. Nevertheless, the number of cases and deaths remain at far higher
levels than those reported earlier.

Among the other communicable diseases, dengue and dengue haemorrhagic fever
are now the most important and rapidly rising arbovirus infections in the
world. There are millions of cases annually, with approximately 500 000
people needing hospital treatment, and thousands of deaths. The ancient
scourge of leprosy still causes 600 000 new cases a year. Between 2 and 3
million people are disabled by the disease, including those who have been
cured but crippled in some way prior to treatment. Onchocerciasis (river
blindness) infects 18 million people in 34 countries, while dracunculiasis
(guinea- worm disease) causes terrible suffering and disability among 3
million of the world s most deprived people who have no access to safe
water. Chagas disease affects 17 million people in 21 countries in Latin
America and causes 45 000 deaths and 400 000 cases of heart and
stomach disease annually. African trypanosomiasis (sleeping
sickness), kills an estimated 55 000 people a year. Schistosomiasis
(bilharziasis or snailfever) affects 200 million people in 74 countries
in the Americas, Africa and Asia and kills perhaps 200 000 people.
Leishmaniasis infects about 13million people. Visceral leishmaniasis,
also known as kala-azar, is the most severe form. Almost always fatal
if untreated, it causes some 500 000 cases and more than 80 000
deaths a year. Lymphatic filariasis (elephantiasis)affects around 100
million people, while Ascaris causes clinical symptoms in as many as
214 million people, Trichuris in 133 million and hookworm in 96
million.

Some 236 million people are estimated to have trichomoniasis, with 94
million new cases a year. Chlamydial infections affect some 162 million
people, with 97 million new cases annually. An estimated 32 million new
cases of genital warts occur each year, and there are some 78 million new
cases of gonorrhoea. Genital herpes infects 21 million people a year, and
syphilis 19 million. More than 9 million people are infected with
chancroid each year.

Many, if not all, STDs could be avoided if condoms were used. Most
STDs can be treated effectively and cheaply - the cost of treating
genital ulcer disease, for instance being between US $0.5 and US $4 per
person. But thereare problems in the supply and accessibility of
services, compounded by fear of stigma on the part of patients and the
attitude of some service providers.

HIV and AIDS continue to spread relentlessly. WHO estimates that in
1994 HIV prevalence among adults worldwide was over 13 million.
Some 6 000 people are becoming infected each day. In parts of Africa
and Asia the virus is advancing rapidly. In southern and south-eastern
Asia HIV infections were estimated at 2.5 million - a million more
than in 1993.

In 1993, 2 065 cases of human plague (with 191 deaths) recorded in 10
countries in Africa, Asia and the Americas were notified to WHO. That
numberexceeded the 1992 total and the annual average for the previous
10 years. The outbreak was a stern reminder to the world that a
dreaded disease, often regarded as a scourge of the past, still exists.

Noncommunicable diseases such as those of the circulatory system
account for10 million deaths globally, with more than 5 million due to
heart disease and another 4 million due to cerebrovascular conditions
(such as stroke). These and other noncommunicable diseases that
primarily affect adults are also emerging as a major cause of death in
the developing world. Although until recently heart disease and stroke
were perceived as problems of the developed countries, about 44% of
total deaths from these causes now occur in the developing world.
Cancer accounts for 6 million or 12% of deaths globally - with the
majority of them, 58%, in the developing world.

Among the other noncommunicable diseases, chronic obstructive
pulmonary diseases such as chronic bronchitis and emphysema killed
nearly 2.9 million adults in 1993, representing about 6% of total
deaths. The number of sufferers in the world from these diseases is
put at 600 million. This is the second largest known category of
persons with a single disorder recorded by WHO. At the same time
there are believed to be 275 million asthma sufferers in the world,
although WHO has no data on the number of deaths due to this condition.

Diabetes mellitus is a growing public health problem in both developed and
developing countries. A recent WHO expert group estimated that more
than 100 million people will suffer from diabetes by the end of this
century - 85-90% with the non-insulin dependent form. In Europe the
prevalence of diabetes is 2-5% per cent of the adult population. In
India a quarter of the populationis affected by the age of 60, and 1 in 5
North Americans will acquire thedisease by the age of 70. One recent
estimate put the cost of diabetes in the USA alone, both direct and
indirect, at US $92 billion a year.

Mental ill-health is at the bottom of the medical pecking order. Only the
most severe cases, such as schizophrenia or manic depression, receive
what minimal care there is, even in developed countries. There are
disturbing signs that society would sooner have such patients
wandering the streets homeless than provide them with the care they
need. The stigma of "madness"is still a potent barrier in preventing ill
people from receiving help. Some500 million people are believed to
suffer from neurotic, stress- related and somatoform disorders. A
further 200 million are affected by mood disorderssuch as chronic and
manic depression. Mental retardation afflicts some 83 million people,
epilepsy 30 million, dementia 22 million and schizophrenia16 million.

Smoking is emerging as the world s largest single preventable cause of
illness and death. WHO estimates that there are about 1.1 billion
smokers in the world today. About 800 million are in the developing
world - nearly three times as many as in developed countries. Smoking
already kills an average of 3 million adults a year worldwide. If
current trends continue, this figure is expected to reach 10 million by
the year 2020.

In the area of women s health and childbirth, the differences in maternal
mortality between countries are shocking. In Europe maternal
mortality is 50 per 100 000 live births. In some of the least developed
countries the rate exceeded 700 maternal deaths per 100 000 births in
1991. In developingcountries 1 in 5 deaths of women of reproductive
age are due to complications of pregnancy and delivery. Half a million
women die every year from conditions which are easily preventable.

The increase in the number of old people in the world will be one of the
most profound forces affecting health and social services in the next
century. Overall, the world s population has been growing at an annual rate
of 1.7% during the period 1990-1995 - but the population aged over 65 is
increasing by some 2.7% annually. Of a world total of 355 million people
over 65 in 1993, more than 200 million are in the developing world, where
they make up 4.6% of the population, with more than 150 million in
developed countries, where the proportion is 12.6%. Although Europe,
Japan and the USA currently have the "oldest" populations, the most
rapid changes are being seen in the developing world, with predicted
increases in some countries of up to 400% in people aged over 65
during the next 30 years.

Alongside the increase in the number of people over age 65, there will
also be a dramatic rise in the numbers of "old old" - people over 80. In
1993 they constituted 22% of those over 65 in developed countries and
12% in the developing world. The world elderly support ratio (the
number of people over 65 years compared to those aged 20-64) in 1990
was 12 elderly to every 100 people of working age. It is estimated
that the figure will be 12.8 in the year 2000 and 13.2 in 2010. In other
words, while population increase during1990-2000 is estimated to be
17%, the increase in the number of elderly is likely to be 30%.

One of the most difficult questions for health planners and politicians
trying to allocate funds, as well as for the community and individuals
themselves, is whether increased life expectancy means more health
or simply more years of sickness. This is an area that is greatly
underresearched, yet the question is assuming ever greater importance.

Two of the most pressing problems in the future will be the provision of
care for people with dementia and those needing joint replacements for
arthritic diseases. WHO estimates that there are 165 million people in the
world with rheumatoid arthritis. The long-term care of the frail elderly is
becoming one of the most debated medical and political issues in many
developed countries, and the developing world too will soon have to
wrestlewith it. If people are not to be left destitute and uncared for at the end
of their lives, more attention must be given to social mechanisms for the
support of the elderly and the means to fund them.

Although in the past 10 years there has been a global trend towards the
democratization of political systems, the much anticipated "peace dividend"
has failed to materialize. Poverty has continued, and will continue, to be a
major obstacle to health development. The number of poor people has
increased substantially, both in the developing world and among
underprivileged

groups and communities within developed as well as developing countries.
During the second half of the 1980s, the number of people in the world
living in extreme poverty increased, and was estimated at over 1.1 billion
in 1990 - more than one-fifth of humanity.

The changing demographic picture across the world, together with the
rapid shift towards urbanization, will have profound implications for
the delivery of health services. The unplanned and often chaotic growth
of megacities in the developing world will pose particular challenges,
as poor sanitation and housing encourage the spread of infectious diseases.

Against any optimism about the global economy throughout the remainder of
this century and beyond should be set a number of major uncertainties. There
has been a disproportionate flow of resources from the developing to the
developed world - poor countries paying money to rich ones - because of debt
servicing and repayment and as a consequence of prices for raw materials
that favour the latter at the expense of the former. Structural adjustment
policies aimed at improving the economic performance of poor countries have
in many cases made the situation worse. The words of Robert McNamara, spoken
in 1980 when he was President of the World Bank, still hold true: "The
pursuit of growth and financial adjustment without a reasonable concern for
equity is ultimately socially destabilizing".

A further worrying global trend is growing unemployment, especially in
developing countries without social security arrangements to cushion those
out of work. Long-term unemployment is creating a new class of
"untouchables" - by excluding a large group of people from the mainstream of
development and society. The unemployed are a potent reminder of the dangers
of assuming that the general prosperity of a country will trickle down to all its members.

There is also considerable concern about the adverse health effects of
continuing environmental degradation, pollution and the uncontrolled dumping
of chemical wastes, diminishing natural resources, depletion of the ozone
layer and predicted global climate changes.

Social mores are also undergoing profound changes, with a move towards
shorter marriages and more divorces in many countries, leading to family
breakdowns which have repercussions for individuals and for social services
that may be called on to provide help for children and single parents.

Beyond any considerations for improving the health of the world must be the
recognition that the growing world population will strain to the limit the
ability of social, political, environmental and health infrastructures to
cope. Health infrastructure - buildings and equipment, the staff, the drugs,
the vehicles - is central to good health care. Services must be integrated,
cost-effective and provided as close as possible to the people who need
them.

With health resources unlikely to be greatly increased but with ever growing
demands for services, because of expanding populations and the advances of
science which make more conditions treatable, the debate about the rationing
of health care, with the attendant ethical problems, is likely to become
intense. Hard choices will have to be made - and greatly enhanced mechanisms
found for listening to the voice of the health consume

WHO's contributions to world health

Within the framework of the organization s constitution and the guidance
given in the periodic general programmes of work, all WHO activities are
geared to respond to the priority problems of the age groups referred to in
this summary. The full extent of WHO's work at national, regional and global
levels cannot be reflected here, but examples are given of different types
of action.

Child and adolescent health

WHO encourages self-reliance of countries in conducting immunization through
basic health services. It cooperates with UNICEF in its initiative
of supplying vaccines to over 100 countries. Major priorities are to at least
sustain the accomplishments of previous years and to continue to strive for
achievement of the 1992 World Summit for Children goal of immunization
against the six vaccine-preventable diseases (diphtheria, pertussis,
tetanus, measles, poliomyelitis, tuberculosis).

In an effort to make the best use of limited resources to eliminate neonatal
tetanus, WHO has given priority to countries that account for 80% of total
cases and have an estimated mortality of 5 or more per 1 000 live births.
WHO initiated a series of measures to arrest the spread of diphtheria in
eastern Europe, including the formulation of a plan of action and the
establishment of a European task force. In 1993 progress towards the
poliomyelitis eradication goal was heartening. Efforts are being made to
develop a more heat-stable poliovirus vaccine that can be delivered with a
less rigorously maintained cold chain. Large donations for poliomyelitis
eradication were coordinated with different organizations. In 1994 the
region of the Americas committed itself to eliminating measles by the year
2000, and incidence is now at the lowest level ever. If the momentum is
sustained the Americas may well lead the way towards global elimination of
this major killer of children.

By the end of 1994 virtually all developing countries had implemented plans
of action against diarrhoeal diseases in children. Nearly 42% of health
staff in the countries had been trained in supervisory skills using
materials developed by WHO, and almost 30% of doctors and other health
workers had been trained in diarrhoea case management, many of them in the
more than 420 diarrhoea training units established in over 90 countries. It
is estimated that nearly 85% of the population of the countries had access
to oral rehydration salts at the end of 1994.

Particular emphasis is given to training in the management of acute
respiratory infections WHO supports courses for workers in first-level
health facilities and referral hospitals on standard case management, and
distributes training and technical materials. More than 190 000 health
managers, doctors, nurses and community health workers in over 60 countries
have been trained so far. WHO is involved in numerous studies on acute
respiratory infections in Africa, Asia and Latin America.

Activities for better nutrition are promoted in 62 countries, mostly in
collaboration with FAO and UNICEF. A global database on child growth was
established and more than 90 countries are receiving technical and financial
support to give effect to the International Code of Marketing of Breast milk
Substitutes. The new WHO/UNICEF "baby-friendly hospital initiative" has
proved hugely successful in encouraging proper infant feeding practices,
starting at birth. It has already been implemented in two-thirds of African
countries. A number of countries have introduced national nutrition policies
with WHO support.

A wide range of WHO programmes focus on the needs of adolescents in such
fields as nutrition, mental health, sexuality, disease and injury
prevention, and substance abuse. A joint UNICEF/WHO/UNFPA policy statement
on the reproductive health of adolescents was disseminated. WHO supported
the formulation of policies on adolescent health in 20 countries.

Health of adults

WHO activities broadly seek to improve and maintain the economic and social
productivity of adults by promoting health and reducing premature morbidity
and mortality.

As far as the major communicable diseases are concerned, efforts are being
made to mobilize financial support to combat tuberculosis, which recently
has shown a worrying resurgence. Control programmes were reorganized in
several countries, and operational and other studies were supported. The
research has produced some important results which may have major
implications for policy. A study of rifapentine suggests that it is a
promising new drug. A large trial is being organized on the efficacy of
sparfloxacin, another new drug, against multidrug-resistant tuberculosis. A
study in Uganda on the feasibility of tuberculosis chemoprophylaxis for
HIV-infected persons suggests that this intervention is not easily
applicable on a large scale in a developing country setting. WHO's global
task force on cholera control continues to support activities to strengthen
national capacity to prepare for and respond to epidemics. Several cholera
vaccines are at different stages of development. All 45 countries where
malaria is endemic received WHO financial support for control activities.
National plans of work, based on a revised regional control strategy, were
drawn up in a number of African countries. WHO, together with other agencies
and NGOs, responded promptly to requests for assistance in combating malaria
epidemics in seven countries, including outbreaks among the 500 000 or so
Rwandan refugees. In view of the rapid spread of chloroquine-resistant and
multidrug-resistant falciparum malaria, a multicentre research programme has
been initiated to study ways of retarding development of drug resistance.
The synthetic Colombian malaria vaccine Spf66 has been shown to be safe, to
induce antibodies and to reduce the risk of clinical malaria by around 30%
among children aged under 5 in the United Republic of Tanzania.

With regard to the other communicable diseases, all countries where leprosy
is endemic have implemented national strategies and plans for elimination of
the disease as a public problem by the year 2000. The onchocerciasis control
programme in West Africa, executed by WHO with support from UNDP, FAO and
the World Bank, has succeeded in eliminating the disease as a public health
problem in 11 endemic countries. Remarkable progress has been made in
eradication of dracunculiasis. National eradication programmes are under way
in the 18 endemic countries. A reliable village-based surveillance system
has also been implemented, with monthly reporting in operation in all
countries. WHO is supporting a campaign to eliminate Chagas disease from the
Southern Cone of the Americas. Activities include the development of
slow-release insecticidal paints which have shown to be nearly twice as
effective as traditional sprays in controlling the triatomine vectors and
about half as expensive. Seven-day treatments with eflornithine have been
shown to be effective against trypanosomiasis. As the drug is expensive, WHO
has arranged to provide it to four countries on a cost-recovery basis, and
is participating in the development of a low-cost synthesis and production
method. Support is given for research and training in the epidemiology and
control of schistosomiasis, and a new candidate vaccine has been identified.
Emergency supplies for serological diagnosis and drug treatment of visceral
leishmaniasis were provided by WHO and UNICEF during a recent epidemic in
Sudan. The outbreak of pneumonic plague in India in 1994 was a stern
reminder that the disease often regarded as a scourge of the past still
exists. WHO intervened promptly at the request of the Indian authorities.
Travel advice was issued based on the International Health Regulations and
an international team of experts was set up to conduct a thorough
investigation. The results suggested that the outbreak involved far fewer
cases than the number reported. No evidence was found of the plague
spreading outside the focus; and no imported, confirmed plague was detected
in any other country.

Programmes against HIV/AIDS are under way with WHO support in most Member
States, including HIV surveillance activities in some 80 developing
countries. Similarly, staff from 80 countries were trained in HIV/AIDS
programme management. Agreements were concluded for bulk purchase of HIV
test kits, ensuring quality and the best possible price for developing
countries. A safety trial of a candidate vaccine against HIV, endorsed by
WHO, was conducted for the first time in a developing country. Policy
guidance is given in such fields as blood safety, restrictions on
HIV-positive travellers and HIV testing. Hundreds of NGOs and networks of
organizations work with WHO in the fight against HIV/AIDS.

WHO is developing a network of centres and a database in support of a global
programme to monitor and prevent cardiovascular diseases, and continues to
coordinate the 10-year, 26-country MONICA project which monitors trends and
determinants in cardiovascular diseases and measures the effectiveness of
interventions. National programmes for the prevention of coronary heart
disease were introduced in 41 countries. Sixteen INTER-HEALTH demonstration
projects have been set up worldwide (9 of them in developing countries) to
assess the effectiveness of integrated community-based intervention. The
related CINDI programme now covers 21 countries in Europe. WHO supports the
implementation of national cancer pain relief and palliative care policies
in 46 countries, and participates in the development of national cancer
registers. A model list of 24 essential drugs for cancer chemotherapy was
updated. Guidelines were produced on ethical issues in human genetics, and
on the provision of genetic services for control of hereditary diseases.
National programmes for control of diabetes and rheumatic diseases were
established in several countries.

Guidelines on mental retardation, epilepsy and suicide and other aspects of
mental health were issued. Studies are promoted on the long-term course and
outcome of schizophrenia and obsessive/compulsive disorders. An
international review of mental health legislation was undertaken. As part of
efforts to prevent substance abuse, recommendations were made on
international control of psychoactive substances and support is given to
Member States in revising policies and legislation on treatment and
rehabilitation of drug and alcohol dependence.

"Africa 2000", a new investment initiative aimed at providing universal
coverage of water supply and sanitation services, was launched. A broad
programme of hygiene education and promotion of low-cost sanitation is being
developed in cooperation with UNICEF and other organizations. Training
packages and manuals on the proper operation, maintenance and optimization
of systems are being prepared, and one on health in water resources
development is being tested. The healthy cities initiative now covers over
650 cities worldwide. The global WHO/UNEP networks for monitoring air and
water quality are operational in more than 60 countries. Revised WHO
guidelines on drinking-water quality were issued. WHO and FAO support the
Codex Alimentarius Commission in promoting the adoption of
scientifically-based national food legislation. Together with FAO, WHO has
established acceptable daily intakes for well over 700 food additives,
contaminants and veterinary drug residues in food.

WHO/UNICEF/UNFPA policy statements were issued on promotion of the health of
women. National safe motherhood action plans were formulated in 10
countries. Databases for monitoring patterns and trends in maternal health
are being disseminated. A total of 87 research projects are funded, many
dealing with the causes of maternal death and disability. A project was
launched to promote simple methods for early detection of cancer of the
cervix and breast in developing countries.

A key objective for WHO is to enable the elderly to exercise their full
potential as a community resource, and to give them a satisfactory quality
of life. Many WHO programmes are involved in this effort, including those
concerned with nutrition, cardiovascular diseases, cancer and palliative
care. A multinational collaborative study on the predictors of
osteoarthritis was launched. In pursuance of the United Nations
international plan of action on aging, WHO is setting up an integrated
programme on aging and health, which will become fully operational in 1996.

General health issues

A global strategy on occupational health was formulated, and country
activities supported. Guidelines and monographs were produced on such
subjects as the health implications of occupational exposure to organic dust
and sensitizing agents as well as selected metals, solvents and pesticides.
Since 1976 WHO has evaluated the health risks posed by exposure to some 200
industrial chemicals and other substances. An international collaborative
oral health research initiative is being set up in collaboration with the
International Dental Federation among others. An international action
network was established on noma and other mutilating diseases and accidents
of the face. Significant progress was made in meeting the rehabilitation
needs of the 35 million persons with disabilities in Africa, using the
community-based district health approach. WHO's global data on blindness
were updated. Training and research in this field is supported by WHO
jointly with NGOs. Quality standards were prepared for small-scale
manufacturers of intraocular implants used in cataract surgery.

As a part of activities to promote healthy lifestyles, a school health
education resource centre and databases were established as well as two
regional networks of health promoting schools. The regions for health
network in Europe was expanded to include 20 regions. National tobacco
control programmes are supported. Recent Winter Olympic events have been
smoke-free, thanks to collaboration between the International Olympic
Committee and WHO.

WHO provides countries with information and guidelines on the organization
of health systems based on primary health care. Technical guidance is given
on the formulation of new health policies and strategies and the
reorganization of health care financing systems.

WHO promotes information exchange between countries in relation to the
development of human resources for health. It has launched an initiative to
determine optimum approaches to the training of health personnel under
changing socioeconomic conditions. Reviews of public health training and
medical education are supported. Fellowships are provided for training in
many health and related fields. National, regional and interregional action
plans for upgrading nursing and midwifery practice are being drawn up
through a network of WHO collaborating centres.

In the field of pharmaceuticals guidelines for drug prescribing are being
expanded. National systems for drug registration, surveillance and quality
assurance are being established in a number of countries with WHO
collaboration. The WHO model list of essential drugs is being revised and
updated. Working with bilateral agencies, other United Nations bodies and
NGOs, WHO collaborates with 55 countries in framing national policies in
such areas as drug selection and legislation. Operational research is
carried out on the rational use of drugs. Guidelines, tools and training
materials have been prepared on many aspects of drug management.

The WHO Global Commission on Women s Health has drawn up an agenda for
action relating to women, health and development. Under the auspices of the
commission, a scheme to provide credit and banking facilities to the most
vulnerable and disadvantaged is being implemented in Africa. At the 1994
International Conference on Population and Development in Cairo, WHO played
a key role in helping to reach a consensus and transcend political and
religious differences. This was made possible by the Organization s medical
and ethical credibility and its inclusive approach to health.

Together with UNDP, WHO promotes recognition of health and environment
concerns in national plans for sustainable development and has given
financial and technical support to six countries for this purpose. WHO has
been designated task manager for the "health chapter" of the 1992 United
Nations Conference on Environment and Development (UNCED). In collaboration
with several United Nations bodies it has prepared a progress report on
health, environment and sustainable development, stressing the importance of
reform with respect to community development, environmental health, national
decision-making and national accounting. Materials produced by WHO included
guidelines on the operation of poisons control facilities, 15 health and
safety guides, and over 200 international chemical safety cards providing
basic information on the diagnosis and treatment of poisonings. Training and
research on the broad topic of health and environment are supported.

WHO worked with 26 countries in greatest need in planning and implementing
health reforms as part of an overall effort for strengthening of national
managerial capabilities. A third report on progress towards health for all
by the year 2000 was prepared for submission to the WHO governing bodies in
1995. Research on health futures was organized; and assessment of the global
health situation and trends in priority diseases and conditions continued. A
total of 184 nongovernmental organizations are now in official relations
with WHO. The growing awareness among Member States of the need to improve
health care delivery systems, and a notable interest on the part of the
World Bank to promote improvements in the social sector, provided a timely
opportunity to forge closer links between WHO, the Bank and governments.
Collaboration was also strengthened with the five major regional development
banks. The traditional good working relations with UNICEF, UNFPA, FAO, ILO
and UNESCO continued.

WHO continues to strengthen national capacity for emergency preparedness and
relief. Technical expertise and emergency medical supplies were provided to
a number of countries including Afghanistan, Angola, Burundi, Iraq, Rwanda,
Somalia, Sudan and some new independent states in 1994. WHO cooperated
closely with the European Union on assistance for the countries of former
Yugoslavia. Ten joint missions were undertaken with WFP for the organization
of food aid in support of human resources development.

Handbooks and guidelines in different fields of health technology were
produced. Progress was made in developing portable laboratory instruments,
solar-run equipment and other types of appropriate technologies.

Up-to-date, authoritative health information is provided to all Member
States through a large number of publications, a series of
widely-distributed periodicals, electronic networks and library services.
WHO facilitates access by countries to a number of databases containing
information on such subjects as communicable diseases and HIV/AIDS. For many
health workers in developing countries, WHO materials are often the only
source of reliable information on health.

By the end of the 20th century we could be living in a world without
poliomyelitis, a world without new cases of leprosy, a world without deaths
from neonatal tetanus and measles, a world without dracunculiasis. In 1993
measles killed nearly 1.2 million children and infected more than 45
million; poliomyelitis killed 5 500 children and as of that year 10 million
people were disabled; leprosy killed 2 400 people and infected 600 000;
neonatal tetanus killed 560 000 newborn babies; dracunculiasis infected 2
million people.

By the end of the century maternal mortality could be half what it was in
1993, when more than 500 000 women died in childbirth. Infant mortality
rates could be no higher than 50 per 1 000 live births. At least 70
countries had higher rates than this in 1993. By 2000 mortality of children
under 5 years could be no more than 70 per 1 000 live births. At least 60
countries had higher rates than this in 1992. We could be living in a world
where less than 10% of babies are born weighing under 2.5 kg. In 1990, 17%
of babies were born below this weight. For babies born at the beginning of
the 21st century life expectancy could be at least 60 years in every country
of the world. In 1993, 50 countries were below this target.

In the year 2000 at least 85% of the world s population could be within one
hour s distance of medical care. In 1993, about 1 billion people had no
access to local health services within a one-hour journey. Deaths from
malaria could be cut by a fifth in at least 75% of affected countries; the
number of deaths and new infections from tuberculosis could be substantially
reduced; the number of new carriers of hepatitis B could fall by 80% as a
result of childhood vaccination; deaths from heart disease in people aged
under 65 could be reduced by at least 15%; all pregnant women could have
proper care.

The year 2000 could see a world where malnutrition among children under 5
years will fall by 50%; where micronutrient deficiencies from vitamin A and
iodine will be eliminated; where the prevalence of iron deficiency anaemia
in women of childbearing age will be reduced by 33%; and where 85% of the
population will have access to safe water and 75% to safe sewage disposal.

These are neither utopian goals nor naïve wishes for a perfect world. They
are achievable - provided the world cares enough and the necessary resources
are made available. WHO sees four main priorities for action in the future.

The first priority is to ensure "value for money" by using the available
resources as effectively as possible and redirecting them to those who need
them most. The aim is to create self-help environments in which men and
women can solve their own problems, establishing and sustaining a
development process that will ensure a brighter future for their children.

The second priority is poverty reduction through better health. Investing in
health saves money as well as lives. It must be accepted that expenditure on
health is not a drain on national resources but a prerequisite for economic
and social progress. Poor health inhibits an individual s ability to work,
reduces earning capacity and deepens poverty. Poverty should thus be tackled
on two fronts: one to meet people s basic minimum needs including access to
health services, housing and education; the other to provide opportunities
for people to earn their way out of poverty through better health and
increased productivity. In addition to the economic aspect there is another
side to poverty which must be corrected - social discrimination and low
status for some groups, particularly women.

The third priority relates to public health policy, which in the decade of
the 1990s has been influenced not only by the health-for-all movement, with
its emphasis on equity, but also by political and economic changes in the
world at large. At the same time it is recognized that ensuring equal access
to health care, a traditional goal of public health authorities, will not
necessarily reduce gaps in health status insofar as disease is determined by
individual behaviour and by the working and living environment. Any genuine
improvement in health will thus call for integrated, intersectoral action in
addressing all the determinants of ill-health. The training of health
professionals will have to be reoriented accordingly.

The fourth priority is to strengthen national capabilities for emergency
relief and humanitarian assistance in the health sector. The new policy of
"emergency management for sustainable development" will provide a bridge
between relief work and development proper, the aim being to reduce human
suffering and economic loss due to epidemics, complex emergencies and mass
population displacements.

The health problems of the future are awesome. Yet much can be done to
tackle them with what we know already. In order to succeed the world will
have to care more, and try harder, but the situation is not hopeless. Martin
Luther King, writing about the civil rights struggle in the United States in
the 1960s, said:"We shall have to repent in this generation, not so much for
the evil deeds of wicked people, but for the appalling silence of the good
people".

Today, as a new generation approaches a new century, it is time for the
appalling silence over global health inequities to be broken.

The evolution of WHO

The first World Health Assembly, held in June 1948 and attended by 53
delegates from WHO's 55 Member States, approved a programme of work that
listed its top priorities as malaria, maternal and child health,
tuberculosis, venereal diseases, nutrition and environmental sanitation.

Today, 47 years later, in spite of significant improvements in human health,
great burdens of suffering and disease are still with us. Half a century of
lessons learned in eradicating and controlling diseases, expanding health
care coverage and making the best use of available resources have guided the
world community, including WHO, on the way to further progress.

The need for a world health organization

At the end of the second world war the majority of the world's people were
still living in extreme poverty and suffering from chronic malnutrition,
communicable diseases and parasitic infections to name a few. Many existing
health services were severely disrupted and huge segments of the population
were excluded from them. The imperative need was therefore recognized for a
new world body capable of grouping resources for health, concerting health
goals and providing a forum for the exchange of health information. The
result was the setting up by the United Nations of a specialized agency to
fulfil that need - the World Health Organization.

Declaring war on disease

WHO's first two decades were dominated by mass campaigns to control diseases
such as leprosy, malaria, smallpox, syphilis, tuberculosis and yaws. Between
1950 and 1965, for instance, 46 million patients in 49 countries were
successfully treated with penicillin against the tropical disease yaws,
making it no longer a significant public health problem in most of the
developing world. By 1955 the number of malaria cases worldwide had dropped
by at least one-third; but by 1970 eradication of the disease was seen to be
impracticable.

The same was not true of smallpox. An eradication campaign that began in
1966, when up to 2 million people a year were dying of smallpox, ended in
1980, when the disease had disappeared from the face of the earth.

These mass campaigns against single diseases gave way to WHO's Expanded
Programme on Immunization aimed at protecting by the year 2000 all children
against six vaccine-preventable diseases - measles, diphtheria, pertussis,
tetanus, poliomyelitis and tuberculosis. Global coverage with the vaccines
reached its peak in 1990, when the goal of immunizing 80% of all children by
the age of 1 year was achieved. The long-term goal of the multiagency
children s vaccine initiative, launched in 1990, is to achieve a world in
which all people at risk are protected against vaccine-preventable diseases,
if possible by means of a single procedure.

Health for all

In 1979 the World Health Assembly unanimously endorsed the Declaration of
Alma-Ata, which stated that primary health care was to be the key to
attaining the goal of health for all by the year 2000.

Consequently global targets for health were established and have since been
the norms against which all health development efforts have been measured.
The strategy of health for all has been endorsed at the highest political
level, but a gap remains between what is preached and what is practised.

Setting the standards

The establishment of standards in such fields as vaccines, drugs and
laboratory tests has been a permanent part of WHO's work. The WHO Expert
Committee on Biological Standardization has met every year since 1951 to
formulate standards which are recognized worldwide. The scientific
credibility of WHO provides a guarantee that everyone accepts.

Training physicians, raising the standards of medical schools in developing
countries and helping countries organize schools for nurses and midwives has
also been a permanent feature of WHO's work. The concept of primary health
care has switched much of the emphasis to training directed towards a wide
range of health care workers at community level, particularly in developing
countries, rather than towards health professionals as such.

The way ahead

WHO's general programmes of work, now covering periods of six years, set out
principles and policies for the functioning of the Organization. They also
provide a framework for detailed workplans and budgeting. Over the years the
programmes have responded to, and often anticipated, the major health
concerns of Member countries. The ninth programme (1996-2001) fixes goals
and targets for WHO's global health action. It focuses on lessening of
inequities in health, control of rising costs, the eradication or
elimination of selected infectious diseases, the fight against chronic
diseases, and the promotion of healthy behaviour and a healthy environment.

The challenge for the future is to mobilize WHO's Member States to adopt
policies and plans that will guarantee the provision of comprehensive
integrated health services for all.