World Health Report 1996

Executive Summary

The World Health Report 1996

Fighting disease, fostering development


A fatal complacency

Until relatively recently, the long struggle for control over infectious diseases seemed almost over. Smallpox was eradicated and half a dozen other diseases were targeted for eradication or elimination. Vaccines protected about eight out of 10 of the world’s children against six killer diseases. Antimicrobial drugs were effectively suppressing countless infections. However, in the path of these successes, cautious optimism has been overtaken by a fatal complacency that is costing millions of lives a year. Infectious diseases are the world’s leading cause of death, killing at least 17 million people – most of them young children – every year. Up to half the 5 720 million people on earth are at risk of many endemic diseases.

Far from being over, the struggle to control infectious diseases has become increasingly difficult. Diseases that seemed to be subdued, such as tuberculosis and malaria, are fighting back with renewed ferocity. Some, such as cholera and yellow fever, are striking in regions once thought safe from them. Other infections are now so resistant to drugs that they are virtually untreatable. In addition, deadly new diseases such as Ebola haemorrhagic fever, for which there is no cure or vaccine, are emerging in many parts of the world. At the same time, the sinister role of hepatitis viruses and other infectious agents in the development of many types of cancer is becoming increasingly evident.

The result amounts to a global crisis: no country is safe from infectious diseases. The socioeconomic development of many countries is being crippled by the burden of these diseases. Much of the progress achieved in recent decades towards improving human health is now at risk.

The struggle for control

Infectious diseases range from those occurring in tropical areas (such as malaria and dengue haemorrhagic fever) to diseases found worldwide (such as hepatitis and sexually transmitted diseases, including HIV/AIDS). Transmission can occur by direct person-to-person contact, through insects and other vectors, by way of contaminated vehicles such as water or food, and in other more complex ways. Today there are ominous trends on all fronts.

A few examples illustrate the impact of infectious diseases on human health and development:

malaria – the worst of the vector-borne diseases – still strikes up to 500 million people a year, killing at least two million;

acute lower respiratory infections kill almost four million children every year. Tuberculosis, similarly spread from person to person, kills three million people annually;

diarrhoeal diseases, mainly spread by contaminated water or food, kill nearly three million young children every year;

the AIDS virus, predominantly transmitted sexually, has already infected up to 24 million adults, of whom at least four million have died. More than 330 million cases of other sexually transmitted diseases occurred in 1995;

viral hepatitis is rapidly emerging as a global health issue. At least 350 million people are chronic carriers of the hepatitis B virus and another 100 million are chronic carriers of the hepatitis C virus. Up to a quarter of them will die of related liver disease. The hepatitis E virus is a major cause of acute hepatitis;

some cancers are caused by viruses (hepatitis B and C among them), bacteria and parasites. WHO estimates that 15% of all new cancer cases could be avoided by preventing the infectious diseases associated with them. Cancer as a whole is the second most common cause of death in many parts of the world. Ten million new cases were diagnosed in 1995.

Breaking the chains

Focusing on the ways in which diseases are transmitted, this report explains the present situation, and the interventions needed to achieve prevention or control. Breaking the chains of transmission is possible. A handful of diseases are within range of elimination or eradication in the next few years and others are under control. Poliomyelitis and guinea-worm disease, for example, could be eradicated by the end of the century. Leprosy could be eliminated as a public health danger. However, the eradication of a disease is an immensely difficult task, fully achieved only once, with the last reported case of smallpox in 1977, and global eradication announced in 1980. This success has not been repeated, due mainly to logistical problems and a series of events and developments, some natural and others man-made, that have occurred in recent years. Some are poverty-related, while others are the consequences of economic prosperity.

Obstacles to success

Poverty exposes hundreds of millions of people to the hazard of infectious diseases in their everyday lives. More than 1000 million people live in extreme poverty. Half the world’s population lacks regular access to the most needed essential drugs.

Continuing global population growth and rapid urbanization force many millions of city dwellers to live in overcrowded and unhygienic conditions, where lack of clean water and adequate sanitation are breeding grounds for infectious disease.

Migration and the mass movement of many millions of refugees or displaced persons from one country to another as a result of wars, civil turmoil or natural disasters, also contribute to the spread of infectious diseases.

As a result of the economic and social crises still affecting many countries, health systems which should offer protection against disease have, in extreme cases, either collapsed or not even been built. The result is a resurgence of diseases that were once under control or should be controllable, given adequate resources. Disabled by these diseases, some societies are unable to get themselves back on their feet.

Increasing international air travel, trade and tourism result in disease-producing organisms being transported rapidly from one continent to another. Reporting of infectious diseases now poses serious economic threats to trade and tourism. Some countries impose unjustified restrictions on travellers coming from infected countries; others are tempted to conceal information about infections within their own borders. The result is a fragmented, uncoordinated approach to infectious disease control and inadequate global information to allow worldwide monitoring.

Changes in global food trade create new opportunities for infections to flourish. They include the shipment of livestock; new methods of food production, storage and marketing; and altered eating habits.

The effects of climate change may allow some diseases to spread to new geographical areas. Microbes continue to evolve and adapt to their environment, adding antimicrobial resistance to their evolutionary pathways.

For all these reasons, controlling infectious diseases is an imperative global challenge that requires a global response.

The global situation – 1995 update

Population. In mid-1995, the global population was about 5720 million people. It is projected to reach 7900 million in 2020, and 9800 million in 2050. By 2050 the least developed nations will have a population of about 1700 million compared with about 589 million today. For the foreseeable future, the heaviest burdens of ill-health are therefore likely to continue to fall on the 80% of the world’s population who live in developing countries, and especially in those countries whose populations are growing fastest and which are least able to sustain economic development.

Urbanization. By 1995, about 2 600 million people, or 45% of the world’s population, were living in urban areas. About 200 million now live in cities with populations exceeding 10 million; the total is expected to be 450 million in the next 20 years, almost all of the increase taking place in the developing world, where already there is a proliferation of slums and squatter settlements with millions of people lacking safe and adequate drinking-water, sanitation and solid-waste disposal facilities. Consequently there are growing risks of waterborne and foodborne diseases.

Fertility. Women are having fewer babies: in 1970, they had an average of 4.7, and the average declined to 3.7 by 1980, to 3.2 by 1990, and is now 3. Increasing use of contraception is the main explanation. In 1995, about 140 million babies were born – 16 million in the industrialized world, 25 million in the least developed countries, and 98 million in other developing countries.

Life expectancy. Globally, average life expectancy at birth in 1995 was more than 65 years, an increase of more than three years since 1985. The life expectancy gap between the industrialized and the developing world has narrowed to 13.3 years in 1995 from 25 years in 1955. But the gap between least developed and other developing countries has widened from seven years to more than 13 years in the same period.

Mortality. About 52 million people died in 1995. The number is almost the same as it was 35 years ago, but the global population has almost doubled in that time. The developing world’s death rate has declined sharply from 20 per 1000 population in 1960 to about nine in 1995, due to mortality reduction particularly in the youngest age groups. The least developed countries lag about 25 years behind other developing nations in the decline in death rates. The rate is highest in Africa.

Child mortality. Defined as the probability of dying by the age of five years, the global average in 1995 was 81.7 per 1000 live births; 8.5 in the industrialized world, 90.6 in the developing world and 155.5 in the least developed nations. Of more than 11 million such deaths in the developing world, nine million have been attributed to infectious diseases, about 25% preventable by immunization.

Emerging diseases

Emerging infectious diseases are those whose incidence in humans has increased during the last two decades or which threatens to increase in the near future. The term includes newly-appearing infectious diseases or those spreading to new geographical areas. It also refers to those that were easily controlled by chemotherapy and antibiotics but have developed antimicrobial resistance.

The most dramatic example of a new disease is AIDS, caused by the human immunodeficiency virus (HIV), whose existence was unknown until 15 years ago. About 26.6 million adults could be living with HIV/AIDS by the year 2000.

A new breed of deadly haemorrhagic fevers, of which Ebola is the most notorious, have struck in Africa, Asia, Latin America and the United States. Ebola appeared for the first time in Zaire and Sudan in 1976 and has emerged several times since, most notably in Zaire in 1995, where it was fatal in about 80% of cases.

The United States has seen the emergence of hantavirus pulmonary syndrome with a case fatality rate of over 50%. Other hantaviruses have been recognized for many years in Asia.

Epidemics of foodborne and waterborne infections due to new organisms such as cryptosporidium or new strains of bacteria such as E. coli O157:H7 have hit industrialized as well as developing countries. A completely new strain of cholera, O139, appeared in south-east India in 1992 and has since spread to other areas of India and parts of South-East Asia.

Despite the emergence of some 29 new diseases in the last 20 years, there is still a lack of national and international political will and resources to develop and support the systems necessary to detect them and stop their spread. Without doubt, diseases as yet unknown but with the potential to be the AIDS of tomorrow, lurk in the shadows.

Antimicrobial resistance

Resistance of diseases to antimicrobials has increased dramatically in the last decade, with a deadly impact on the control of diseases such as tuberculosis, malaria, cholera, dysentery and pneumonia. As a result people with infections are ill for longer periods and are at greater risk of dying, and epidemics are prolonged.

Resistant organisms have no natural barriers; aided by international air travel they can move quickly from remote locations to have a worldwide impact. As resistance spreads, the effective life span of drugs shrinks; as fewer new drugs appear, the gulf widens between infection and control. In the case of malaria there is a double threat: on the one hand the malaria parasites are resistant to antimalarial drugs, and on the other the malaria-carrying mosquitos are resistant to insecticides. Rapid development of malaria drug resistance has already occurred in most areas of the world.

Resistant strains of the tuberculosis bacilli are also widespread: there have been alarming outbreaks of tuberculosis caused by multidrug-resistant strains in the United States. Both of the organisms that cause pneumonia, a major cause of death in children, are becoming increasingly resistant to drugs. The same is true of salmonellae, a leading cause of foodborne infections, and enterococci bacteria, which cause a host of complications in hospital patients. Hospital infections are a huge problem worldwide and are responsible for 70 000 deaths a year in the United States alone.

Person-to-person transmission

The combination of population growth (especially in cities), international air travel, incessant migration and the ebb and flow of refugees means that the peoples of the world are more intermingled now than at any time in history. Thus human transmission could become the predominant way in which diseases are spread quickly, not just from person to person but from continent to continent – by airborne and droplet spread, sexual transmission, bloodborne transmission or direct contact.

In children, the major diseases disseminated by airborne and droplet spread are acute respiratory infections, particularly pneumonia, influenza, measles, pertussis (whooping cough), meningococcal meningitis and diphtheria, which together kill at least four million. Direct contact diseases in children include poliomyelitis and trachoma, a major cause of blindness in developing countries. Among adults, tuberculosis is the leading airborne disease, killing three million people and infecting almost nine million others every year. It is already the opportunistic infection that most frequently kills HIV-positive people: of an estimated one million AIDS-related deaths in 1995, about one-third may have been due to tuberculosis. Leprosy still affects 1.8 million people in 70 countries, but is steadily being eliminated as a public health problem. Influenza and pneumonia strike children and adults, especially the elderly.

Of all sexually transmitted diseases, HIV/AIDS continues to have the greatest global impact, with an estimated 20 million adults currently affected. In addition to HIV, at least 333 million new cases of other sexually transmitted diseases occurred in 1995.

Among bloodborne infections, hepatitis causes most concern. More than 2000 million people alive today have been infected with hepatitis B; some 350 million are chronically infected and thus at risk of serious illness and death from liver cirrhosis and liver cancer. In addition, some 100 million are chronically infected with the hepatitis C virus. Unlike hepatitis B, there is no vaccine for hepatitis C.

Foodborne, waterborne and soilborne diseases

Almost half the world’s population suffers from diseases associated with insufficient or contaminated water and is at risk from waterborne and foodborne diseases, of which diarrhoeal diseases are the most deadly. They caused over three million deaths in 1995, 80% of them among children under age five. Typhoid fever causes about 16 million cases and over 600 000 deaths a year, about 80% of them in Asia. There are epidemics of cholera and dysentery, with cholera alone causing 120 000 deaths a year. Seventy-nine million people are estimated to be currently at risk of cholera infection in Africa. Worldwide, some 40 million people have intestinal trematode infections. However, dracunculiasis (guinea-worm disease) could be eradicated in the next few years; about 122 000 cases were reported in 1995 compared to 3.6 million in 1986.

Foodborne diseases have a major impact throughout the world. Estimates in the United States range from 6.5 million to 80 million cases a year. The leading foodborne bacteria worldwide are salmonellae, campylobacter, Escherichia coli and listeria. Foodborne viruses include hepatitis A, also common worldwide.

Soilborne infections affect several million people a year, intestinal worm infections being the most widespread. The most deadly soilborne disease is tetanus, which annually kills at least 450 000 newborn babies, and 50 000 mothers around the time of childbirth.

Insect-borne diseases

Of all disease-transmitting insects, the mosquito is the greatest menace, spreading malaria, dengue and yellow fever, which together are responsible for several million deaths and hundreds of millions of cases every year. Mosquitos also transmit lymphatic filariasis and Japanese encephalitis. Other insect species carry a variety of diseases. Sleeping sickness is spread by the tsetse fly, with 55 million people at risk. The leishmaniasis group of diseases is spread by sandflies, with 350 million people at risk. Another 100 million in Latin America are at risk of Chagas disease, spread by household bugs. Onchocerciasis, or river blindness, is carried by blackflies, and plague by fleas.

Malaria is endemic in 91 countries, with about 40% of the world’s population at risk. By undermining the health and working capacity of hundreds of millions, it is closely linked to poverty and stunts social and economic development. Up to 500 million cases occur every year, 90% of them in Africa, and there are up to 2.7 million deaths annually.

Dengue is the world’s most important mosquito-borne virus disease, with 2500 million people worldwide at risk of infection and 20 million cases a year in more than 100 countries. In 1995, the worst dengue epidemic in Latin America and the Caribbean for 15 years struck at least 14 countries, causing more than 200 000 cases of dengue fever and almost 6000 cases of the more serious dengue haemorrhagic fever.

Many major cities of the world, especially in the Americas, are at risk of potentially devastating epidemics of yellow fever because they are infested with Aedes aegypti mosquitos which can transmit the disease. Lymphatic filariasis (elephantiasis) infects about 120 million people in tropical areas of Africa, India, South-East Asia, the Pacific Islands and South and Central America.

Among diseases spread by other insects, leishmaniasis occurs in 88 countries, and its spread is accelerated by road building, dam construction, mining and other development programmes that bring more people into contact with the sandflies that transmit the causative parasite. Sleeping sickness affects 36 countries of sub-Saharan Africa. Onchocerciasis affects some 17.6 million people in Africa, and a smaller number in Central and South America. At least 16 million people in Latin America are infected with Chagas disease. Plague continues to strike relatively small numbers of people in Africa, the Americas and Asia.

Diseases from animals

Rabies is the most serious disease spread from animals to humans, causing around 60 000 deaths a year. About 10 million people a year receive treatment after being exposed to animals suspected of having rabies. Dog rabies remains a threat in at least 87 countries with a total of 2400 million people at risk. Human brucellosis, caught from farm animals such as cattle, sheep, goats and pigs, is reported in at least 86 countries.


Emerging issues in infectious disease control

WHO has strengthened its capacity to combat new and re-emerging infectious diseases, and can now mobilize staff and place teams on site within 24 hours of notification of an outbreak, together with the supplies and equipment required to implement epidemic control measures, as was the case with the outbreak of Ebola haemorrhagic fever in Zaire in 1995. To prepare for such emergencies, WHO uses innovative field technology and public health training programmes to support country surveillance and disease control, and is developing a network of public health laboratories to strengthen regional and international collaboration in the detection and control of outbreaks.

As part of its work in detecting and monitoring resistance to antimicrobials, WHO has established an information system (WHONET) to support the global surveillance of bacterial resistance to antimicrobial agents, with the participation, by the end of 1995, of 177 laboratories in 31 countries or areas.

Infectious diseases transmitted from person to person

WHO has been active with partners, including UNICEF, in controlling diphtheria epidemics in the Russian Federation, some newly independent States and Mongolia. National immunization days were organized in late 1995, targeting the vulnerable population aged between 16 and 40.

In view of the fact that in some countries tuberculosis control programmes are being overwhelmed by the growing prevalence of HIV infection, WHO is mobilizing national experts to develop a new research strategy aimed at preventing the collapse of those programmes. The Organization is promoting the “directly observed treatment, short-course” (DOTS) strategy as the key to halting the current epidemic. In 1995 WHO issued training materials and a handbook on the subject of tuberculosis and supported workshops in 15 countries.

Steady progress is being made towards the elimination of leprosy as a public health problem before the end of the century, as a result of the multidrug therapy recommended by WHO since 1981, which is relatively cheap, is acceptable to patients and effects a complete cure.

In February 1995 WHO announced the composition of the influenza vaccine for the 1995-1996 season, replacing two of the three components that had been included in the vaccine for the previous season.

WHO studies were carried out on various aspects of HIV/AIDS, such as the protective effect of the female condom; the efficacy of a long-acting vaginal microbicide; preparation of field-testing sites for vaccines; preventing mother-to-child transmission; and a number of sociological investigations. Training in condom promotion continued in most regions. WHO was involved in the setting up of a Joint United Nations Programme on HIV/AIDS (UNAIDS), which became operational on 1 January 1996.

Foodborne, waterborne and soilborne diseases

WHO concluded an agreement with Swiss Disaster Relief to provide technical assistance in epidemic diarrhoea control and preparedness, and established links with other agencies and organizations working in the same field. For instance, collaboration began with the International Federation of Red Cross and Red Crescent Societies in the newly independent States of eastern Europe and central Asia.

Under the southern African initiative for control of epidemic diarrhoea, a team in Harare continued to coordinate activities aimed at improved preparedness and response to outbreaks of cholera and epidemic dysentery. Five African countries received support in the areas of policy formulation, developing surveillance systems and strengthening laboratory services. Surveillance and control strategies were set up in refugee camps in the United Republic of Tanzania and in Zaire. Six African countries faced with outbreaks of cholera or dysentery received technical assistance and emergency supplies.

WHO reassessed the distribution and prevalence of schistosomiasis in the world and its social and economic impact. Trials demonstrated the safety and efficacy of a combination of albendazole against common intestinal helminths and praziquantel against schistosomiasis.

Dracunculiasis (guinea-worm disease) is on the verge of eradication. WHO’s priorities are to achieve the interruption of transmission as quickly as technically feasible, and to facilitate the work of the independent International Commission for the Certification of Dracunculiasis Eradication (created in 1995) by setting up and conducting the certification process. The objectives are to search for remaining, unknown foci of the disease; to verify whether low-risk countries are dracunculiasis-free; and to secure the necessary funding to complete the eradication process.

As part of its efforts to prevent foodborne diseases, WHO is studying the microbiological contamination of foods and patterns of human behaviour that may lead to the growth or survival of Vibrio cholerae and other foodborne pathogens. The Organization issued a report recommending measures to control newly emerging foodborne pathogens such as trematodes. The Joint FAO/WHO Codex Alimentarius Commission ensures that internationally agreed food standards, guidelines and other recommendations are consistent with health protection. Following the creation of the World Trade Organization, the Codex now serves as the international reference for national requirements.

Insect-borne diseases

WHO helped to fight malaria on many fronts in 1995. It established an interregional system for monitoring drug resistance in South-East Asia and the Western Pacific; supported research on such subjects as drug regimens and new diagnostic techniques; provided training for programme managers, specialists, district medical officers and community health workers; issued training materials; and assisted in control measures in refugee camps in Burundi, Rwanda, United Republic of Tanzania, and Zaire. WHO-led research enabled scientists to modify the genes of Plasmodium falciparum, the deadliest malaria parasite, opening up the possibility of developing new techniques for diagnosis and drug and vaccine development.

The only effective way to prevent dengue fever and dengue haemorrhagic fever is to eliminate the mosquito vectors or drastically reduce their numbers. The WHO control programme recommends selective, integrated vector control; active surveillance; emergency preparedness; capacity-building and training; and research on vector control. With WHO support, national control programmes have been developed in Indonesia, Myanmar and Thailand.

WHO participated in the implementation of the vaccination campaign that controlled the epidemic of jungle yellow fever in Peru in 1995, the largest outbreak recorded since 1950.

The Organization provided technical support and diagnostic reagents and assisted in vaccine procurement for the immunization strategy used to control Japanese encephalitis in endemic areas of India, Sri Lanka and Thailand.

New control tools and elimination strategies are being used in the fight against lymphatic filariasis (elephantiasis). Multicentre trials have shown that single-dose diethylcarbamazine, single-dose ivermectin, and especially combinations of the two drugs, are all effective and safe.

WHO set up a leishmaniasis surveillance network of 14 institutions worldwide, endorsed diagnostic guidelines and established a central epidemiological registry. The Organization cooperated with Sudan and Bangladesh in combating this disease. The results obtained from using insecticide-impregnated bednets in six countries are promising.

WHO prepared guidelines for the control of African trypanosomiasis (sleeping sickness) on behalf of Angola and Zaire, developed plans of action for several countries, and established a revolving fund for the supply of drugs to national programmes. Clinical trials are under way to ascertain whether shorter treatment schedules and lower dosages of pentamidine and melarsoprol may be just as effective as those currently used.

To combat onchocerciasis, the WHO, World Bank, UNDP and FAO joint Onchocerciasis Control Programme was launched in 1974. It has carried out vector control activities and distributed the drug ivermectin free of charge, curing 1.5 million people of the disease and opening up vast tracts of fertile land for resettlement and cultivation. The new African Programme for Onchocerciasis Control will continue to draw on the support of several United Nations agencies and nongovernmental organizations.

The campaign to eliminate Chagas disease from Argentina, Brazil, Bolivia, Chile, Paraguay and Uruguay is making good progress. House infestation rates have declined by 75%-98% in various affected areas.

Infant, child and adolescent health

Since 1960, infant mortality has fallen from 130 to 60 per 1000 live births and child mortality has fallen from 180 to 80 per 1000 live births. Immunization against six vaccine-preventable diseases (diphtheria, pertussis, tetanus, measles, tuberculosis and poliomyelitis), undertaken with intensive support from WHO, UNICEF and the international community, has saved millions of children annually from death and disability. By 1995, the goal of 80% coverage for these vaccines (except tetanus toxoid) had been achieved globally, but 25 countries (19 in Africa) still reported coverage below 50% for all six vaccines. Comprehensive plans of action were developed in six African countries, but major efforts are urgently needed to cover the remaining 19 countries.

Since the goal of global eradication of poliomyelitis was set in 1988, reported cases of the disease have declined by about 85%.

For the past four years global measles immunization coverage has remained at about 80%; since immunization began, the number of cases has declined by 70% and the number of deaths by 83%. The disease is targeted for elimination in the Americas by the year 2000, and in other regions, many countries are pursuing innovative immunization strategies.

Substantial progress has been made globally in the elimination of neonatal tetanus, particularly in the Americas and South-East Asia. More than 700 000 deaths are now being prevented annually through routine immunization of women with tetanus toxoid, and through improved hygienic birth practices. In 1980, 76 countries reported less than one neonatal tetanus death per 1000 live births annually; by 1995 the number of countries had increased to 122.

Every year diarrhoea, pneumonia, measles, malaria or malnutrition – or a combination of them – kill more than eight million children. Three out of every four children brought for health care suffer from at least one of these conditions. Child health programmes need to address the sick child as a whole rather than single diseases. WHO and UNICEF therefore jointly developed an approach for the integrated management of the sick child, which gives due attention to both prevention and treatment of childhood disease. The WHO/UNICEF course Management of childhood illness enables health workers in outpatient clinics and health centres to manage infant and childhood illnesses effectively in an integrated fashion. The course is based on treatment guidelines developed by WHO and covering the most common potentially fatal conditions.

WHO provides normative information on monitoring, prevention and management of major crippling forms of malnutrition, with emphasis on protein-energy malnutrition, micronutrient malnutrition such as iodine deficiency disorders, vitamin A deficiency, and nutritional anaemia. The Organization also gives support to countries in dealing with infant and young child nutrition in emergency situations.

Recent research has confirmed strong links between health, school attendance and educational attainment. WHO’s global school health initiative is concerned with the various hazards to which the world’s school-age children and adolescents – more than 1000 million, almost 700 million of whom are of primary school age (6-11 years) – are exposed, such as injuries, sexually transmitted diseases and substance abuse.

Health of adults and the elderly

WHO promotes community-based prevention of noncommunicable diseases as the strategy to reduce risk factors and morbidity and increase life expectancy. In 1995 the Organization continued to coordinate four major cardiovascular disease research projects and supported epidemiological surveys (for instance, on diabetes) in several countries. It also supported the development of national programmes for the control of major hereditary diseases and congenital malformations, and monitored international human genome research.

WHO’s INTERHEALTH project has revealed unfavourable nutrition trends globally: in most countries the availability of dietary fat is increasing, whereas the availability of vegetable protein and total carbohydrates, particularly starch, is decreasing. WHO encourages countries to reduce malnutrition and promote good nutrition, and provides normative guiding information on the prevention, management and monitoring of malnutrition. Forty-seven Member States have adopted education programmes aimed at preventing noncommunicable diseases related to lifestyle and diet.

The key to cervical cancer control is health education, early detection and screening. Recognizing that such control is feasible, even in developing countries, WHO has pioneered pragmatic, realistic approaches for its early detection by visual inspection, for affordable radiotherapy and for the relief of pain and symptoms in incurable cases. The International Agency for Research on Cancer, which coordinates and conducts epidemiological and laboratory research aimed at developing strategies for cancer prevention, in 1995 published conclusive evidence of the role of human papilloma virus as a cause of cervical cancer. The agency is also assessing potential vaccines against the virus and investigating methods of screening for precancerous and cancerous lesions of the cervix.

Recognizing that reproductive health is central to health in general, and thus to socioeconomic development, WHO has set up a new programme on this subject that brings together various related activities and ensures better coordination of research and technical support. The new programme will draw up a comprehensive strategy, define norms and standards, and develop technical tools for addressing reproductive health concerns in countries.

A major issue for WHO in the field of aging and health is healthy aging in women. The third meeting of the Global Commission on Women’s Health focused on the health conditions that women face later in life and strategies that will help older women enjoy good health and an improved quality of life.

Environment and lifestyles

WHO is cooperating with UNDP, the World Bank and UNICEF to develop community participation approaches in the area of water supply and sanitation which can also be effective in changing hygiene behaviour. As coordinator of the Water Supply and Sanitation Collaborative Council’s working group on promotion of sanitation, WHO supports several initiatives to raise awareness of the need for improved sanitation and promotes the partnership roles of international agencies, donors, ministries, nongovernmental organizations and academic institutions in this respect.

The Healthy Cities network is expanding and achieving specific environmental improvements, for instance in reducing urban air pollution. The Global Environmental Monitoring System is tackling the problem of identification and control of emission sources. Capacity for management of air quality has been assessed in 20 cities to identify immediate needs for technical cooperation.

WHO has collaborated with UNDP, the World Bank and the United Nations Centre for Human Settlements in establishing a comprehensive strategy on the increasingly serious problem of disposal of health care wastes, in particular in urban areas.

The Organization is developing an action plan, covering the period to the beginning of the twenty-first century, in the areas of health promotion and health education, building infrastructures around existing economic and other arrangements and WHO’s regional structure. South Africa is taking the lead in southern Africa, and Hungary in Europe. A health promotion alliance is developing between the more populated countries, including China, India, Indonesia, the Russian Federation and the United States.

Health care, organization and management

In the area of health infrastructure, WHO gave technical support to several low-income countries to ensure the inclusion of health considerations in economic development projects. Research is being planned with the object of improving urban health services. A health system research network was set up linking countries of North, Central and South America. Regional task forces for this type of research were set up in the Eastern Mediterranean and South-East Asia. In Europe, the focus is on the countries of eastern Europe, where health systems research is especially weak.

WHO launched an initiative for reorienting medical education and public health training towards the twenty-first century. The Organization and the Kellogg Foundation supported Bolivia, Mexico and Zimbabwe in taking practical measures to establish an optimally balanced and productive workforce of health care personnel. WHO also supported training in health care financing and health insurance and in quality assurance. The Organization continued, through its fellowships programme, to provide opportunities for carefully selected health professionals to obtain the necessary skills to direct, guide and support health development in their countries, within the framework of careful human resources planning and clearly defined priorities.

At the World Summit for Social Development (Copenhagen, March 1995), WHO advocated strengthening partnerships for health development and mobilizing the political commitment to view it in the context of economic and social development. The Organization directs action and resources towards countries rather than specific programmes, emphasizing the links between poverty and ill-health through its focus on intensified cooperation with countries and people most in need. This initiative has 28 participating countries, and WHO has cooperated with them in developing health policy, strengthening health systems and putting sustainable health financing schemes in place. In addition, the Organization works with other agencies and with donors to ensure a more focused and increased flow of funds and their more effective use by countries. It also supports countries in ensuring regular access to essential drugs.

WHO continued in 1995 to disseminate health information widely, in the shape of epidemiological and statistical data, reports, guidelines, training modules and periodicals. For this purpose, increasing use was made of informatics and telematics, including Internet.

With a view to improving coordination, WHO seeks collaboration with other intergovernmental and nongovernmental organizations active in the health field. Within the framework of the United Nations system and its Administrative Committee on Coordination, an initiative for African economic recovery and development was launched, with health sector reform and disease control as one of its components. During 1995 WHO strengthened its collaboration with the World Bank and several regional development banks, the Organization for African Unity and the European Union.

During 1995 WHO was extremely active in the field of emergency relief, assisting in relief efforts in 55 Member States, conducting emergency preparedness activities in 10, and cooperating in safety promotion and injury control in 11.


The situation described in the report – the emergence or re-emergence of certain infectious diseases and increasing resistance to antibiotic drugs – constitutes a serious crisis requiring immediate action. Some of the diseases can be controlled, eliminated or eradicated, for instance, by means of immunization, personal hygiene and/or public health and sanitation practices. The proper use of antimicrobial drugs and vector control methods have a part to play in the fight against certain diseases. All these measures can lead to a rapid reduction in infectious diseases and thus enhance overall development, provided that there is political and professional commitment to finance and sustain well-planned, cost-effective interventions.

The diseases concerned can be conveniently classified in three categories, each requiring a different type of intervention. First, there are what may be termed “old diseases – old problems“: those that can be eradicated (poliomyelitis, dracunculiasis), eliminated as public health problems (leprosy, neonatal tetanus, measles, Chagas disease, onchocerciasis) or controlled (cholera and other diarrhoeal diseases, intestinal worms, hepatitis, typhoid). What is needed is the commitment and resources to undertake the following cost-effective interventions (the per capita cost in low-income countries is indicated in most cases):

(1) immunization of children against six vaccine-preventable diseases – diphtheria, pertussis, tetanus, poliomyelitis, measles and tuberculosis (US$ 0.50);

(2) the integrated approach to the management of the sick child (US$ 1.60);

(3) provision of adequate clean drinking-water and of basic sanitation facilities and collection of household garbage, as well as the simple hygienic measures of washing hands after defecation and before preparing food;

(4) school health programmes treating worm infections and micronutrient deficiencies and providing health education (US$ 0.50);

(5) case management of conventional sexually transmitted diseases using simple algorithms to decide on the appropriate diagnosis and treatment in peripheral health facilities (US$ 11).

The second category of diseases – “old diseases – new problems” – are tuberculosis, malaria, dengue and other vector-borne diseases. Cost-effective interventions exist, but drug or pesticide resistance poses a problem, requiring the use of additional or more expensive or toxic drugs. The strategy for controlling these diseases includes such interventions as early diagnosis and prompt treatment, vector control measures and the prevention of epidemics, for malaria; as well as directly observed treatment, short-course (DOTS) therapy for tuberculosis; undertaking research on treatment regimens and improved diagnostics, drugs and vaccines; and above all, epidemiological and drug-resistance surveillance mechanisms and procedures with laboratory support for early detection, confirmation and communication.

The natural history and the reasons for the emergence of the third category – “new diseases – new pathogens” – such as Ebola and other viral haemorrhagic fevers, is not well understood. Research is therefore needed on the disease agents, their evolution, the vectors of disease spread and methods of controlling them, and vaccines and drug development. Much of this already applies to HIV/AIDS, one of the most serious diseases to emerge in recent decades. The strategy required includes improving surveillance systems and public health infrastructure, strengthening laboratory services, and responding rapidly to urgent threats to public health. WHO is developing a global surveillance programme to recognize and respond to emerging diseases, making maximum use of existing WHO collaborating centres. A further component is WHONET, the computer programme that is designed to facilitate management of the results of antibiotic susceptibility tests, for use by microbiology laboratories.

Epidemics of various infectious diseases have been occurring repeatedly in several countries. As a result, there is now an international consensus that priorities have to be set and activities initiated speedily. This favourable environment for action needs to be exploited, and in WHO’s view there are three priorities for international action during the next five years.

The first priority is to complete unfinished business, namely to complete the eradication and elimination of diseases such as poliomyelitis, dracunculiasis, leprosy, measles, Chagas disease and onchocerciasis. This does not require a huge expenditure, and if the resources are not found, these diseases will return with a vengeance, and previous efforts will be wasted.

The second priority is to tackle old diseases such as tuberculosis and malaria which present new problems of drug and insecticide resistance. Here there is a need to remove infectious sources in the community and cure a high proportion of infectious cases, establish appropriate national and international epidemiological surveillance, and undertake research on treatment regimens and improved diagnostics, drugs and vaccines. Work is needed on developing new and improved vaccines against measles, neonatal tetanus, bacterial meningitis, tuberculosis and other diseases.

The third priority is to take short-term and long-term action to combat newly emerging diseases. A speedy response is needed to outbreaks of important new infections, wherever they occur. At the same time, there is a need for intensive research on the natural history of new diseases and on possibilities for preventing, treating and controlling them. A global surveillance programme is also essential.

The world health report 1995 indicated how poverty could be alleviated by enabling the poor to earn their way out of poverty and by enhancing their health potential through measures for preventing diseases, promoting positive health and protecting people against health hazards, thereby improving their social and economic productivity. The world health report 1996 outlines opportunities that now exist for improving the health of the present generation while laying the foundation for better health for future generations.


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