The World Health Organization (WHO) - Activities

Under the global "health for all" strategy, WHO and its member states have resolved to place special emphasis on the developing countries. Nevertheless, the benefits of WHO's international health work are reaped by all countries, including the most developed. For example, all nations have benefited from their contributions to the WHO programs that led to the global eradication of smallpox and to better and cheaper ways of controlling tuberculosis.

Prevention is a key word in WHO. The organization believes that immunization, which prevents the six major communicable diseases of childhood—diphtheria, measles, poliomyelitis, tetanus, tuberculosis, and whooping cough—should be available to all children who need it. WHO is leading a worldwide campaign to provide effective immunization for all children in cooperation with UNICEF.

Provision of safe drinking water and adequate excreta disposal for all are the objectives of the International Drinking Water Supply and Sanitation Decade proclaimed by the UN General Assembly in 1980 and supported by WHO.

WHO is also active in international efforts to combat the diarrheal diseases, killers of infants and young children. The widespread introduction of oral rehydration salts, together with improved drinking water supply and sanitation, will, it is hoped, greatly reduce childhood mortality from diarrhea.

WHO's program for primary health care comprises eight essential elements:

1. education concerning prevalent health problems and the methods of preventing and controlling them;
2. promotion of food supply and proper nutrition;
3. maintenance of an adequate supply of safe water and basic sanitation;
4. provision of maternal and child health care, including family planning;
5. immunization against the major infectious diseases;
6. prevention and control of locally endemic diseases;
7. appropriate treatment of common diseases and injuries; and
8. provision of essential drugs.

These eight elements were defined in the Declaration of Alma-Ata, which emerged from the International Conference on Primary Health Care, held in Alma-Ata, USSR, in 1978.

A. Disease Research, Control and Prevention

UNAIDS Programme

The Acquired Immune Deficiency Syndrome (AIDS) pandemic is an international health problem of extraordinary scope and urgency. The mission of UNAIDS is to mobilize an effective, equitable, and ethical response to the pandemic. It strives to raise awareness, stimulate solidarity, and unify worldwide action. UNAIDS works with countries to develop programs to prevent HIV transmission and reduce the suffering of people already affected. It provides technical and policy guidance to governments, other United Nations agencies, and non-governmental organizations. It also promotes and supports research to develop new technologies, interventions, and approaches to AIDS prevention and care. Its inception in 1988 was first as the Global Programme on AIDS. UNAIDS combines the efforts of six other UN system organizations, including UNDP, the World Bank, UNICEF, UNFPA, WHO, and UNESCO. Since January 1996, the joint and co-sponsored UN Programme on HIV/AIDS, or UNAIDS, has been operational to better coordinate fund raising and prevention efforts.

WHO estimated in 2002 that more than 42 million people were living with HIV/AIDS. It was also estimated that during 2002, 5 million people (including 800,000 children under the age of 15) became infected. It was estimated that in 2002, 3.1 million adults and children died because of HIV/AIDS. In 2002, approximately 610,000 of these deaths occurred among children and 1.2 million (50%) were among women. The total number of deaths worldwide due to HIV/AIDS since the beginning of the epidemic until the end of 2001 was 21.8 million. Of the 42 million people living with HIV/AIDS in 2002, 29.4 million (approximately 70%) lived in Sub-Saharan Africa, the region that has been hardest hit by AIDS/HIV.

The disease is caused by a virus which destroys the body's innate capacity to withstand disease (the immune system). As the immune system is weakened, infected persons can no longer resist diseases which cause diarrhea, fatigue, severe weight loss, and skin lesions. Eventually, the AIDS-related illnesses cause death. Persons become infected with the HIV virus by contact with body fluids like semen (during sexual intercourse) or blood (if they receive contaminated blood during a transfusion). Intravenous drug users who share hypodermic needles have been shown to be at great risk for contracting HIV. HIV cannot be transmitted by air or simple touch. The insidious nature of the disease contributed to its silent explosion into the world population, since infected persons do not show signs of infection for as many as six to ten years.

AIDS was already an international epidemic (a "pandemic") by the time it was first recognized in 1981. In late 1983, WHO held the first international meeting on AIDS in Geneva. In February 1987, WHO established its Special Programme on AIDS in order to develop a global strategy for AIDS control, obtain financial resources, and begin implementation of the program. In 1988, the Executive Board renamed it the Global Programme on AIDS (GPA). Today it is known as UNAIDS Programme. The main objectives of the global strategy are:

• to prevent HIV infections;
• to reduce the personal and social impact of HIV infection; and
• to mobilize and unify national and international efforts against AIDS.

The global strategy was updated in 1992 to place increased emphasis on:

• health care for AIDS patients;
• treatment for sexually transmitted diseases;
• improving the status of women in developing countries in order to reduce the risk of infection;
• providing more frank information about AIDS;
• planning for the socio-economic impact of the pandemic;
• overcoming stigmatization and discrimination directed at persons infected with HIV/AIDS.

A World Summit of Ministers of Health on Programmes for AIDS Prevention was held in London in January 1988. The summit proclaimed 1 December as Worlds AIDS Day. In 1989 the World Health Assembly resolved to make World AIDS Day the annual focus for worldwide efforts against AIDS. That same year, WHO established a Global Commission on AIDS to provide the Director General with broad policy and scientific guidance from eminent experts representing a wide variety of disciplines. By the end of 1991, AIDS programs had been established in every WHO member country.

In June 2001, the General Assembly held a Special Session on HIV/AIDS, at which 189 member states adopted a "Declaration of Commitment," setting forth a plan to establish time-bound targets to which governments and the UN might be held accountable. They included the goal to reduce by 2005 HIV prevalence among young men and women aged 15 to 24 in the most affected countries by 25%, and by 25% globally by 2010. Also, it was hoped that by 2005, an overall target could be reached of annual expenditure on the epidemic of between US $7 billion and US $10 billion in low and middle-income countries and those countries experiencing or at risk of experiencing rapid expansion for prevention, care, treatment, support and mitigation of the impact of HIV/AIDS.

On 12 December 2002, a new international alliance, the International HIV Treatment Access Coalition (ITAC), was launched in Geneva and Dakar. It aims to boost efforts to provide access to antiretroviral drugs to the growing number of people with HIV/AIDS in low and middle income countries.

Tuberculosis

In April 1993, WHO declared a tuberculosis (TB) global emergency. WHO said that 35 years of neglect by governments, and a linkage to the HIV/AIDS pandemic, had led to a resurgence of the bacillus that causes tuberculosis. In New York City, the incidence of TB rose 150% between 1980 and 1993, prompting WHO to declare a global TB epidemic. The link between HIV/AIDS and tuberculosis, which were fueling each other, was so pronounced that by 1994 WHO called the phenomenon a co-epidemic. The breakdown in health services, the spread of HIV/AIDS, and the emergence of strains of TB that are multidrug-resistant contributed to the worsening impact of the disease. As of 2002, the global epidemic was growing and becoming more dangerous: Tuberculosis was killing 2 million people a year. Health experts estimated that between 2000 and 2020, nearly one billion people would be newly infected, 200 million people would get sick, and 35 million would die from TB if the disease was not controlled.

Tuberculosis is an age-old killer, traces of which have been found in the lungs of 3,000-year-old Egyptian mummies. It is caused by a bacillus that infects the lungs, forming knobby lesions called "tubercles." Up until the 20th century it was commonly called "consumption." Today the bacillus responsible for TB is called Mycobacterium tuberculosis. The first diagnostic test was discovered in 1905 and the first vaccine was created in France in 1921. The first antibiotic effective against TB, streptomycin, was discovered in 1944 in the United States. By 1960, chemotherapy for TB was so effective, sanitoria in mountain areas which had been used for more than a century to care for TB patients were closed. TB was presumed dead, at least in the industrialized world: public health measures for TB control were dismantled, and funding for research fell to a trickle. However, multidrug-resistant (MDR) strains began to flourish as patients being treated with antibiotics neglected to completely finish a course of treatment. In New York City, MDR strains accounted for only 7% of all TB strains in the early 1980s. By 1992, more than one-third of the strains tested were resistant to one drug, and almost one-fifth were resistant to the two main drugs.

WHO contends that the rise of tuberculosis in the industrialized world is linked not only to HIV/AIDS, but also to inadequate funding of international programs to combat tuberculosis in the developing world. The organization has insisted that it will be impossible to control TB in the industrialized countries unless it is sharply reduced in Africa, Asia, and Latin America.

The WHO Tuberculosis Programme aimed to cut the annual death toll from TB from 3 million deaths in 1992 to 1.6 million by 2002, but that goal was not reached. WHO predicts that about US$ 100 million needs to be spent each year to provide medicines, microscopes, and a modest infrastructure enabling poor countries to undertake successful tuberculosis programs. WHO reports that in the developing world, a complete cure could cost as little as US$ 13 per patient. However, the treatment of a patient with a multidrug-resistant strain of TB in New York City could cost US$ 180,000 per patient.

As of 2002, WHO targets were to detect 70% of new infectious TB cases and to cure 85% of those detected. Six countries had achieved these targets by 1998. But WHO stated that governments, non-governmental organizations, and civil society must continue to act to improve TB control in order to reach these targets worldwide.

The Tropical Disease Research Programme

The UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) was set up in 1975 to target malaria, schistosomiasis (bilharzia or "snail fever"), leishmaniasis, African trypanosomiasis (sleeping sickness), American trypanosomiasis (Chagas disease), lymphatic filariasis (which leads to elephantiasis), onchocerciasis (river blindness), and leprosy. Almost 500 million people, nearly all of them in developing countries, suffer from these diseases, which can cause terrible anguish, deformity, and death. At the same time, they cause considerable economic losses and frequently interfere with development projects (particularly water projects such as dams and irrigation schemes, and planned and unplanned forestry).

The death toll from the diseases—particularly among children from malaria in Africa—is expected to double by 2010, possibly reaching four million lives a year, unless radical solutions are found. Population increase, the spread of parasite resistance, mass migrations, environmental disturbance, and disruption of control programs through economic devastation, civil unrest, and wars, all contribute to the tropical disease problem.

TDR has a mandate to:

1. Develop new methods of preventing, diagnosing, and treating tropical diseases, methods that would be applicable, acceptable, and affordable by developing countries, require minimal skills or supervision, and be readily integrated into the health services of these countries.
2. Strengthen—through training in biomedical and social sciences and through support to institutions—the capability of developing countries to undertake the research required to develop and apply these new methods.

In this work, TDR collaborates closely with WHO's Division of Control of Tropical Diseases (CTD), and with many other WHO programs and outside bodies concerned with tropical disease research and control.

TDR acts to some extent like a research council, supporting investigator-initiated projects selected by peer-review, and to some extent as a pro-active agency commissioning the research required to reach its objectives. A quarter of TDR's funds goes to research capability strengthening (RCS) in developing countries. This RCS work is being increasingly combined with the performance of needed research: "training by doing."

Over the eighteen years of TDR's existence, a large number of drugs, diagnostic techniques, vector control agents, and other products have been developed, and in conjunction with national and international control programs there has been considerable success in applying these to reduce (or potentially reduce) the burden of some of the tropical diseases—notably leprosy, onchocerciasis, and Chagas disease. The other diseases still pose major problems, either globally or regionally.

TDR's research targets, and the appropriate management and decision-making structure to reach those targets was thoroughly reviewed in 1992–93. A new structure, initiated in 1994, gave the program greater focus on priority targets and more flexibility to identify and respond to the practical health and control needs of populations. The structure is divided into three functional areas: basic and strategic research (STR); product research and development (PRD); and research capability strengthening (RCS).

Basic and Strategic research. STR activities are divided into three areas, each of which is managed through a steering committee: pathogenesis and applied genomics; molecular entomology; and social, economic and behavioural research. The pathogenesis and applied genomics committe emphasizes using genome information and advances in functional genomics to understand the mechanisms leading to disease and to the survival of parasites and viruses. The molecular entomology committee focuses on malaria and dengue research, aiming to develop ways to replace natural mosquitoes in the wild with mosquitoes that are unable to support the development of malaria parasites or the dengue virus. The third committee supports research to investigate how social, behavioral, political, economic, and health factors affect disease patterns and control.

Product research and development . This arm of TDR is divded into three areas. Product discovery focuses on the discovery of new compounds, and the research is managed by a drug research committee and a vaccine research committee. Product development develops molecules to the regulatory approval and registration stage. And diagnostics research and development combines discovery and the development of new diagnostics.

Research Capability Strengthening . This program of TDR was established to strengthen the capacity of disease-endemic countries to carry out and sustain research. Specifically, RCS aims to promote and fund research training and institution development, and increase the participation of developing countries' TDR research and development agenda.

TDR's particular strength is that, as part of the United Nations system, it enjoys a world view of the tropical disease scene and the standing conferred by a lack of partisan or profit-making motivation. These assets explain in large measure TDR's rapid success in creating an international network of over 5000 scientists, which gives it access to a broad range of expertise and scientific disciplines.

Through its WHO connection, TDR has ready access to programs and units working in related fields and—most importantly, with its new focus on the field and on national control programs—to WHO's 192 Member States. TDR can call on government support in endemic regions in order to engage populations and facilities in multi-center field trials rapidly and at very low cost.

Leprosy

Leprosy, also known as Hansen's disease, has been a serious public health problem in the developing countries. But the widespread use of multidrug therapy (MDT) has reduced the disease burden dramatically. In the last 15 years of the 20th century, 10 million leprosy patients were cured, the prevalence rate dropped by 85%, and the number of countries where leprosy remained a public health problem dropped from 122 to 24. Once the prevalence rate at the global level is reduced to less than one case per 10,000 persons, health experts believe there will be a natural interruption of transmission over time and future generations will not contract the disease.

At the end of the 20th century, the prevalence rate at the global level was 1.4 cases per 10,000 people. At the beginning of 2002, the number of leprosy patients in the world was around 635,000, as reported by 106 countries. About 760,000 new cases were detected during 2001. It was estimated that about 2.5 million patients would be detected between 2000 and 2005.

In the late 1990s, leprosy remained a public health problem in 24 countries situated mainly in the inter-tropical belt of the world. Of the 24, it was estimated that 12 (Cameroon, Chad, Congo, Côte d'Ivoire, Ethiopia, Gabon, Gambia, Guinea-Bissau, Mali, Papua New Guinea, Paraguay, Sierra Leone) would meet the elimination goal in the year 2000 if strategies were intensified and accelerated. WHO reported that special efforts would be needed to eliminate leprosy in 12 other countries: Angola, Brazil, Central African Republic, Democratic Republic of the Congo, India, Indonesia, Guinea, Madagascar, Mozambique, Myanmar, Nepal, and Niger. Together these 12 countries represented 90% of the prevalence in the world in 1999. As of 2002, the countries most affected by leprosy were Angola, Brazil, India, Madagascar, Mozambique, Myanmar and Nepal.

In order to eradicate leprosy, WHO stated that political commitments needed to be strengthened in countries where leprosy remained a public health problem. Additionally, it said that strong leadership by ministries of health was absolutely necessary, particularly in some of the major endemic countries. Finally, the organization estimated that US $100 million was needed for the period 2000–05, of which US $54 million had been pledged through 1998.

Malaria

As of 2002, WHO reported that malaria was a public health problem in more than 90 countries, inhabited by a total of some2.4 billion people or roughly 40% of the world's population. At the time, worldwide prevalence of the disease was estimated to be approximately 300 clinical cases a year, with more than 90% of the cases occurring in sub-Saharan Africa. Of those contracting the disease, an estimated one million die each year, with the majority of deaths occurring among young African children. WHO stated that other high-risk groups were pregnant women, and non-immune travelers, refugees and other displaced persons, and workers entering endemic areas.

Malaria has been a priority for WHO since its founding in 1948. Control activities are coordinated by WHO's Programme on Communicable Diseases (CDS). The four basic technical elements of WHO's global control strategy are: provision of early diagnosis and prompt treatment for the disease; planning and implementation of selective and sustainable preventive measures; early detection for the prevention or containment of epidemics; and, strengthening local research capacities to promote regular assessment of malaria situations, in particular the ecological, social and economic determinants of the disease.

In 1992, WHO convened a Ministerial Conference on Malaria in Amsterdam which was attended by health leaders from 102 countries and representatives of United Nations bodies and nongovernmental organizations. The conference endorsed a global malaria control strategy. WHO planned to implement control programs in 90% of the countries affected by the disease no later than 1997. The target was to reduce mortality by at least 20% between 1995 and 2000.

WHO has published many books in support of its fight against malaria, including: A Global Strategy for Malaria Control, Basic Malaria Microscopy, Parasitic Diseases in Water Resources Development, and books in many languages on the diagnosis and treatment of malaria.

Smallpox

The eradication of smallpox is among the finest achievements of WHO, which coordinated the international effort to combat this disease. It is the first time in history that a human malady has ever been totally eliminated. This became feasible because the virus causing the disease was transmitted only by direct human contagion; there were no animal reservoirs or human "carriers." Victims of the disease were immune to further attacks, while successful vaccination at three-year intervals gave essentially complete protection.

Eradication was based on a twofold strategy of surveillance containment and vaccination. Rapid detection of cases, their immediate isolation, and the vaccination of anyone with whom the patient could have come in contact during the infective period, lasting about three weeks after the onset of rash, prevented further transmission. Implementation of these procedures, coupled with the basic immunity level attributable to routine immunization, resulted in the eradication of smallpox everywhere in the world.

Although a global program of eradication was initiated in 1959, it was not until 1967, when a special WHO budget with increased bilateral and multilateral support was prepared, that a definitive target date of 10 years was set for global eradication. By the end of 1977, this goal was achieved.

In 1967, 131,776 cases of smallpox were reported from 43 countries, 31 of which were classified as smallpox-endemic; however, the actual number of cases was estimated to have been between 10 million and 15 million, among whom possibly 1.5 to 2 million died. Since that time, WHO has convened many international commissions which certified smallpox eradication in 79 recently endemic countries. The global eradication of the disease was declared by the World Health Assembly in 1980. By 1985, all WHO member states had discontinued routine smallpox vaccination, and no country required smallpox vaccination certificates from international travelers.

By 1993, the complete nucleotide sequence of the genomes of several strains of the virus had been determined, fulfilling the requirements set in 1990 for the final destruction of the remaining stock of variola virus. On 9 September 1994, an expert committee agreed that the destruction of the remaining clinical specimens of variola virus should take place on 30 June 1995, after confirmation by the May 1995 meeting of the World Health Assembly. The committee also recommended that 500,000 doses of smallpox vaccine be kept by WHO in case of an emergency and that the vaccine seed virus be maintained in the WHO Collaborating Centre on Smallpox Vaccine in Bilthoven, Netherlands.

In the wake of the 11 September 2001 terrorist attacks on the United States, many countries began to take definitive steps toward preventing such attacks, including those that might come from biological weapons. Five people in the United States died as a result of anthrax sent throught the U.S. postal system in late 2001. Those events led to concern about the possibility of smallpox being used as a biological weapon. After UN Security Council Resolution 1441 was passed on 8 November 2002, calling on Iraq to immediately disarm itself of all weapons of mass destruction (nuclear, biological, and chemical), and to allow UN and IAEA weapons inspectors to enter the country, the United States announced a policy of smallpox vaccination. Smallpox vaccinations were given to select groups of Americans, including 500,000 military personnel and 500,000 civilian health care workers. The vaccine given to this population was the same as that used to eradicate smallpox as of 1980. Once a new vaccine was to be manufactured and licensed, estimated in 2004, it would be made available free to Americans who want it.

In 2002, the WHO announced that an approximate 200 million smallpox vaccine doses were available around the world, in addition to new purchases made by the United States. Much of the vaccine was old, frozen for several decades, but new types had been produced. Countries seen as likely terrorist targets were undertaking precautions against possible smallpox attacks. In 2002, they included Australia, which bought 50,000 doses of smallpox vaccine, and dedicated US $11.4 million to anti-bioterrorism measures; Israel, which offered 15,000 emergency workers voluntary smallpox innoculations in 2002, and stated it had enough vaccine for everyone in the country, including the West Bank and Gaza; the United Kingdom, which announced it had plans to vaccinate emergency workers and to stockpile vaccine; Germany, which asked its states to buy smallpox vaccine for every resident, and itself purchased 6 million doses in 2002 (enough to vaccinate 24 million individuals when diluted); and Japan, which by 2002 spent US $47.5 million on bioterror preparations, and planned to obtain 10 million smallpox doses by 2003.

Cholera

In 1961, cholera caused by Vibrio cholerae 01 El Tor began to spread from its endemic locations and gradually invaded practically all countries in the Western Pacific and Southeast Asia regions, most of which had been free from cholera for many years. Cholera continued to spread westward, reaching Pakistan, Afghanistan, Iran, and Uzbekistan (USSR) in 1965 and Iraq in 1966. In 1969 and 1970, it created great problems in the Middle East, North and West Africa, and Europe and has since spread to most countries of Africa, becoming endemic in many of them. Its spread has been facilitated by the fact that most of the persons who come in contact with El Tor vibrio become mild cases or carriers of the disease. Between 1984 and 1990, reported cases of cholera had increased from 28,893 to 70,084, a 142% increase. By 1991, cholera had completed its spread around the globe and appeared in Latin America for the first time in this century. Extensive epidemics also recurred in Africa. In 1991, reports received by WHO indicated that 594,694 people contracted cholera, and of that number, 19,295 people died, more than in the previous five years combined.

Numerous field and laboratory studies showed that the control measures were not sufficiently effective. The anticholera vaccines in use, when tested in controlled field trials, were shown to protect at most about half the persons vaccinated and for less than six months. Some vaccines provided no protection at all.

In view of these findings, WHO intensified its research activities in improving treatment and vaccines; it also worked to reinforce the ability of governments to face the problem of cholera within the framework of control programs directed against diarrheal diseases in general.

A simple and inexpensive oral-rehydration treatment, proven effective in the 1970s for all acute diarrhea, has made cholera treatment substantially easier. As most of the cases of El Tor vibrio cholera cannot be differentiated from other diarrheal diseases on clinical grounds, WHO has developed a comprehensive and expanded program for the control of all diarrheal diseases, including cholera.

In April 1991, WHO created a Global Task Force on Cholera to strengthen global control efforts and improve preparedness. A new strain Vibrio cholerae O139 emerged in the period 1992–93, causing new epidemics and largely replacing El Tor vibrio . Reinforced efforts around the globe brought the disease under control during the 1990s: In 1998, the number of new cases dropped to 293,121, of which 10,586 died; in 2000, the raw figures decreased again—to some 140,000 cases resulting in approximately 5,000 deaths. Africa accounted for 87% of these cases.

Other communicable diseases

WHO continues to monitor and sponsor research on influenza, viral hepatitis, arthropod-borne viruses, yellow fever, Japanese encephalitus, bubonic plague, meningitis, Legionellosis, and streptococcal infections.

Diseases Transmissible Between Animals and Man (Zoonoses) and Related Problems

Since its inception, WHO has been developing veterinary public health programs in cooperation with its member states. In the 1970s, WHO's veterinary public health program was reoriented toward more direct collaboration with member states in the development of national and intercountry programs in which zoonoses and food-borne disease control receive the highest priority. This action was justified because these diseases have become increasingly prevalent in many countries mainly as a result of the following factors: the greatly expanded international and national trade in live animals, animal products, and animal feedstuffs, which facilitates the spread of infection; the growth of urbanization, coupled with the increased numbers of domestic and half-wild animals living in close association with city populations, which exposes more people to zoonoses; and changing patterns of land use, such as irrigation, together with new systems of animal farming, which may lead to changes in the ecology that disseminate and increase animal reservoirs of zoonoses.

The 1978 World Health Assembly adopted a resolution on "prevention and control of zoonoses and food-borne diseases due to animal products" in which member states were invited to formulate and implement appropriate country-wide programs for the control of zoonoses; to strengthen cooperation between national veterinary and public health services in improving the surveillance, prevention, and control of these diseases; and to collaborate further in ensuring the appropriate development of zoonoses centers. The resolution also requested the director-general of WHO to continue development of national, regional, and global strategies and of methods for the surveillance, prevention, and control of zoonoses, and to promote the extension of the network of zoonoses centers in all regions so that the necessary support could be provided to country health programs dealing with these diseases.

WHO cooperates with member states in planning, implementing, and evaluating their national zoonoses and food-borne disease control programs. WHO centers, such as those in Athens (Mediterranean Zoonoses Control Center) and Buenos Aires (Pan American Zoonoses Control Center), play an increasing role in direct collaboration with countries and in organizing intercountry technical cooperation.

Global Epidemiological Surveillance

In the Weekly Epidemiological Record, WHO publishes notes on communicable diseases of international importance and information concerning the application of international health regulations. In the past, the publication was chiefly a summary of the weekly or daily notifications of diseases under the regulations, with declarations of infected areas or of freedom from infection when attained. It then became the vehicle for timely reports, narrative summaries, and interpretative comments on a variety of communicable disease topics. Annual, semiannual, or quarterly summaries are published on major trends in diseases and on special programs, such as those on malaria and AIDS. Data from special surveillance programs, such as the global influenza program, the European program for salmonella, and dengue-hemorrhagic fever surveillance, are summarized and published at appropriate intervals. The Weekly Epidemiological Record also communicates important changes in international health regulations and policies of member states.

Global Programme for Vaccines and Immunization

Immunization, one of the most powerful and cost-effective weapons of disease prevention, remains tragically underutilized. Preventable diseases such as neonatal tetanus and poliomyelitis, which have been virtually eliminated in most of the developed world, continue to take a heavy toll in developing countries. Measles, whooping cough, diphtheria, and tuberculosis are serious health threats to children in developing countries, causing blindness, deafness, and even death. In 1993, WHO reported that 8 million children were dying annually in developing countries from viral and bacterial illnesses, and 900 million were becoming severely ill.

The Expanded Programme on Immunization (EPI). In 1974, with the help of UNICEF, UNDP, national donor agencies, and voluntary agencies, WHO initiated the Expanded Programme on Immunization, with the goal of providing immunizations for all children of the world by 1990.

In 1974, it was estimated that immunization coverage in the developing world was less than 5%. By 1987, coverage of children in developing countries in their first year of life with one dose of BCG and measles vaccines and three doses of DPT and poliomyelitis vaccines was reported to be between 45% and 55%. That level of immunization coverage was preventing over 1 million deaths and almost 200,000 cases of paralytic poliomyelitis a year in the developing world. In its coordinating role, WHO gave priority to the managerial training of health workers and the development of cold-chain systems in order to provide for the establishment of vaccine delivery mechanisms capable of achieving high coverage of susceptible populations with vaccines known to be safe and effective. WHO estimated that in 1990 alone, immunization programs reached more than 100 million infants each year, and saved 3.2 million children annually from measles, neonatal tetanus and pertussis. However, approximately 2.1 million children were still dying each year from the preventable diseases included in the EPI. Little progress had been made in extending coverage to hard-to-reach populations, and coverage in Africa had even begun to decline.

In 1993, WHO, UNICEF, UNDP, the World Bank, and the Rockefeller Foundation founded the Children's Vaccine Initiative (CVI). The Initiative undertook the research and development of a heat-stable oral poliomyelitis vaccine, a single-dose tetanus toxoid vaccine, and an improved measles vaccine which could be given earlier in life. In 1994, the EPI and the Children's Vaccine Initiative were merged into the Global Programme for Vaccines and Immunization (GPV) , which also took over the activities of the WHO/UNDP Programme for Vaccine Development. The GPV was established to sustain the accomplishments of the EPI and the CVI, to achieve the goals for immunization and disease control set by the World Health Assembly and the World Summit for Children, and to add new and improved vaccines as they become available.

By 1999 the Global Programme for Vaccines and Immunization became the Department of Vaccines and Biologicals. Based on World Health Assembly targets, three major objectives were defined for the department: (1) innovation, including facilitating the development of new vaccines, simplifying immunization, and accelerating the introduction of new or improved vaccines (pneumococcal, Hib, rotavirus, and hepatitis B vaccines were given top priority); (2) establishing immunization systems, including increasing coverage to 90%, strengthening the system for epidemiological surveillance, and assuring the safety of vaccines; and (3) accelerated disease control through the eradication of polio by 2000, reducing measles cases by 90%, eliminating neonatal tetanus, and eliminating vitamin-A deficiency.

In June 2002, the European Region of the WHO was certified "polio free." That region included 870 million people living in 51 member states, stretching from Iceland to Tajikinstan, and including the Russian Federation.

On 20 November 2002, the State of the World's Vaccines and Immunization report was launched, which highlights the importance of immunization as one of the most effective public health inititatives, and advocates for international support to speed progress for child health and disease control in developing and industrialized countries. The report examines the progress made in the field of immunization, and outlines the vaccines research agenda for the 21st century. It also offers policy options for promoting investment into immunization systems.

B. Prevention and Control of Noncommunicable Diseases

Cancer

Cancer, a noncommunicable disease, has been ranked as the second or third main cause of death globally among persons who survive the first five years of life. Contrary to the general belief that cancer occurs mainly in the industrialized world, it is estimated that more than half of all cancer patients today are in developing countries. By the year 2015, the annual figure is expected to reach 15 million cases, and by 2020, 20 million new cases. Some 70% of these are expected to occur in developing countries, which, as of the late-1990s, together had less than 5% of the resources for cancer control. Dramatic increases in life expectancy, combined with changes in lifestyles, were expected to lead to global epidemics of cancer and other chronic, non-communicable diseases. In 1997 alone, cancer claimed more than 6 million lives, or 12% of all deaths worldwide, and these figures continued to rise through the end of the decade.

Cancer Strategies for the New Millennium, an international conference, was convened in London in October 1998. It was attended by more than 100 professionals from 26 countries. At the event, WHO Cancer Programme chief Karol Sikora said action was needed from national governments working in close partnership with the private sector. WHO announced plans to work to reduce the global incidence of cancer by five million per year and reduce mortality by six million per year by 2020. "It's imperative that the private sector play its part since resources have become over-stretched and the lives of millions of people are seriously at risk. Together, we can make a difference," said Sikora. WHO Director-General Dr. Gro Harlem Brundtland added that these goals were attainable given new strategies that are aimed at an integrated approach to cancer prevention, early detection, curative treatment, and palliative care. At the core of these strategies is the "cancer priority ladder," which provides internationally accepted priorities for developing effective national control program. The steps of the ladder include tobacco control, a curable cancer program, a healthy eating program, effective pain control, referral guidelines, clinical care guidelines, nurse education, a national cancer network, clinical evaluation, a clinical research program, a basic research program, and an international aid program. WHO said it would support such efforts by offering to its 191 member states a comprehensive program of expertise, channeled through national ministries of health and health departments.

The International Agency for Research on Cancer, located in Lyons, France, is associated with WHO and conducts research on identification of carcinogenic factors in the environment, as well as lifestyle factors in cancer development.

Cardiovascular Diseases

The MONICA Project. WHO coordinated the Monitoring of Trends and Determinants of Cardiovascular Diseases (MONICA) which was established in 1979 and became operational in 39 collaborating centers located in 26 countries in October 1984. The MONICA project was the largest collaborative epidemiological study of these diseases ever carried out. It followed 25 million people between 25 and 64 years of age over a 10-year period, collecting data on coronary deaths, non-fatal heart attacks, coronary risk factors, and coronary care. By 1993, the main results from the MONICA study were: cross-sectional comparisons of risk factor levels; relations between various risk factors; five-year trends in risk factors; acute coronary care; medical services; cross-sectional comparisons of incidence rates for stroke; and management of stroke around the world. Several optional studies are being carried out in connection with MONICA on nutrition, anti-oxidant vitamins, polyunsaturated fatty acids, physical activity and psychosocial studies, and drug monitoring.

The MONICA data center was established at the National Public Health Institute in Finland, and prepared the data collection instruments and methodology for the study. It receives and analyzes the data collected. In 1993 the MONICA study entered its final stage of data collection. The final results of the study were made available in 1998 and were made accessible online at www.ktl.fi/monica .

Substance Abuse

Tobacco Use. Cigarette smoking is one of the principal preventable causes of premature mortality and ill health, particularly in industrialized countries but also in developing countries, where it is spreading. As of 2002, approximately 1.1 billion people in the world smoked, or 1 in 3 adults. According to WHO estimates in early 2000, there are 4 million deaths a year from tobacco, a figure expected to rise to about 10 million by the 2020s or early 2030s. By that date, based on smoking trends, tobacco was predicted to be the leading cause of disease burden in the world, causing about one in eight deaths. Seventy percent of those deaths were expected to occur in developing countries. Smoking has been shown to be linked with circulatory complications in women using oral contraceptives, cause lower body weight in newborns of smoking mothers, decrease male and female fertility, and be associated with cancers of organs other than the lungs. Passive smoking causes a higher frequency of upper respiratory tract infections in children exposed to tobacco smoke. In adults, it is associated with a significantly higher risk of lung cancer among exposed nonsmokers. Tobacco chewing causes cancer of the mouth.

Tobacco use is considered as a dependence disorder in WHO's International Classification of Diseases. WHO has taken the lead in international action to stem the spread of smoking and its harmful health consequences. It collaborates with numerous national smoking and health associations around the world, as well as with nongovernmental organizations and other UN agencies. WHO collaborating reference centers assist in analyses of toxic components of cigarettes. Seminars and conferences muster scientific knowledge and political support.

In 1988, the World Health Assembly declared 31 May as a "World No Tobacco Day" to focus public attention and recognize contributions to healthy life-style free from tobacco use. In 1989 the WHA approved a plan of action on a program called "Tobacco or Health." The program promoted national tobacco control programs; provided advocacy and information services; and acted as a clearinghouse for activities in the field.

To improve the global response to tobacco as an important health issue, in July 1998, WHO Director-General Dr. Gro Harlem Brundtland established the Tobacco Free Initiative (TFI). The long-term mission of global tobacco control is to reduce smoking prevalence and tobacco consumption in all countries and among all groups, thereby reducing the burden of disease caused by tobacco. In support of this mission, the stated goals of the TFI are to: strengthen global support for evidence-based tobacco control policies and actions; build new partnerships and reinforce existing partnerships for action; heighten awareness of the social, human and economic harm of tobacco in all sectors of society, and the need to take comprehensive actions at all levels; accelerate national, regional, and global strategic planning, implementation and evaluation; commission policy research to support rapid, sustained, and innovative actions; mobilize adequate resources to support action; integrate tobacco into the broader agenda of health and development; and facilitate the development of an effective Framework Convention for Tobacco Control and related protocols. In achieving these goals, WHO stated that TFI would build strong internal and external partnerships with each WHO cluster and regional and country offices, and with a range of organizations and institutions around the world. WHO has also been instrumental in heightening awareness of World No-Tobacco Day (May 31 each year).

Alcohol and Drug Abuse. WHO is the executing agency for the United Nations Fund for Drug Abuse Control. In collaboration with the International Narcotics Control Board and the United Nations Division of Narcotic Drugs, WHO has prepared guidelines on drug-abuse reporting systems that give special attention to data on health, to complement the law enforcement data that are traditionally gathered. In 1991, WHO held an Inter-regional Meeting on Alcohol-Related Problems in Tokyo, which recommended a number of actions to reduce alcohol dependence in member states. In the 1992/93 biennium, the Abuse Trends Linkage Alerting System (ATLAS) was set up to gather health-related data from a variety of sources in order to assist in mobilizing efforts to reduce demand for dependence-producing substances. In 1993, WHO supplied global data on substance abuse for the World Bank's publication of World Development Report 1993: Investing in Health.

To better lead the fight against substance abuse, WHO established a Substance Abuse Department (SAB), which promoted the agency's "health for all" concept by working to reduce the incidence and prevalence of substance abuse. In the 1990s SAB began developing programs, coordinating research, and working with existing health departments and other organizations to curtail demand for alcohol and drugs (psychoactive substances). SAB placed emphasis on intervention research on the effects of urbanization and drug abuse among young people; developing a global database of model program and best practices; strengthening country capacity to reduce alcohol abuse; and reducing HIV/AIDS-associated risks and consequences of substance abuse. In 2000, the Substance Abuse Department was merged with the Department of Mental Health (see "Mental Health" below) to form the Department of Mental Health and Substance Dependence.

C. Primary Healthcare and Health Building

Family Health

"Health for all" requires that special attention be paid to specific population groups whose health and welfare have profound social, demographic, and economic implications for society. The health of mothers and children is particularly important because of the special biological and psychosocial needs inherent in the rapid process of human growth, needs which must be met in order to ensure the survival and healthy development of the fetus and the child, as well as to maintain the health and development of the mother. The health of young people is also important, since the energy and idealism of youth are important resources that can be channeled to the benefit of their societies.

WHO assists governments in the application of preventive, curative, and rehabilitative measures aimed at promoting and protecting the health of women and children and at strengthening the role of all family members in health care and child rearing. WHO's primary approaches are the following: (1) to identify the extent and nature of the major health needs of mothers, children, and young people; (2) to develop and adapt methods for the promotion of healthy behavior and the protection of women, children, and adolescents during vulnerable periods of rapid physiological and social changes, particularly relating to reproduction; (3) to provide technical guidance in the planning, management, and evaluation of preventive and curative programs of maternal and child health, including family planning; (4) to introduce and adapt training approaches for improving knowledge and skills in interpersonal and group communication and counseling, the health rationale for family planning, and innovative maternal and child health/family planning technologies; (5) to disseminate information on the health needs of women, children, and adolescents and on new ways of addressing those needs; (6) to identify and support research in basic clinical and applied aspects of pediatrics, adolescent medicine, gynecology and obstetrics, social psychology, and health systems; (7) to collaborate in the activities of national and international organizations concerned with maternal and child health/family planning and young people; and (8) to contribute to the development of intersectoral policies and programs.

In 1992, the World Health Assembly established the Global Commission for Women's Health (GCWH). The commission is composed of eminent persons from different professional fields and acts as an advisory body to the Directory General, providing independent scientific and technical advice on policies and strategies relating to women's health. The commission meets once a year.

At the commission's fifth meeting, in February 1997, US First Lady Hillary Rodham Clinton joined the GCWH in setting out a comprehensive agenda on the issue of maternal morbidity: According to WHO, the annual global estimated toll is close to 600,000 deaths (one woman dying every minute of every day) and eight million cases of disability from pregnancy-related causes. The GCWH dedicated itself to future advocacy to ensure that the tragedy of women dying in childbirth was not ignored. The First Lady noted WHO's progress in women's health made since 1995's Beijing World Conference on Women. The Platform for Action, adopted by the Beijing Conference, highlighted the need to ensure universal access to appropriate, affordable and quality health care and services for women and girls as one of the 12 critical areas of concern requiring urgent attention by governments and the international community.

The agenda for women's health was furthered at the Beijing+5 conference, "Women 2000: Gender Equality, Development and Peace for the Twenty-first Century," held June 2000 in New York City. Among the topics that were discussed at the forum were death during childbirth, HIV/AIDS and other sexually transmitted diseases, women in control of their own fertility, and malnutrition.

Reproductive Health

In 1993, the WHO Global Policy Council approved the following definition of reproductive health to provide a basis for action in this field. "Within the framework of WHO's definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions, and system at all stages of life. Reproductive health implies that people are able to have a responsible, satisfying, and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this last condition are the right of men and women to be informed of and to have access to safe, effective, affordable, and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant."

Nutrition

In addition to developing criteria and norms for assessing nutritional status, WHO strives to strengthen the capacities of countries to assess and evaluate their nutritional problems and associated factors and to develop and implement sectoral strategies to deal with the causes of those problems. Increasing the awareness of the world community of those problems for which solutions have been designed and tested has resulted in a significant increase in national programs to control iodine-deficiency disorders and vitamin A deficiency. At the same time, improvements in factors that have an influence on nutrition, such as disease prevention and management, food production, and education, have resulted in a decreased prevalence of undernutrition.

The International Conference on Nutrition, held in Rome in December 1992, was the culmination of more than two years' joint effort by WHO and FAO to promote awareness of the extent and seriousness of nutritional and diet-related problems. The conference was attended by more than 1,300 people representing 159 governments and some 160 international and nongovernmental organizations. The conference adopted the World Declaration and Plan of Action for Nutrition which declared its determination to eliminate hunger and reduce all forms of malnutrition, and called on the United Nations to declare an International Decade of Food and Nutrition. The conference attendees estimated that 780 million people in developing countries do not have access to enough food to meet their daily needs. It reaffirmed the right of women and adolescent girls to adequate nutrition. The conference set ambitious goals of eliminating famine and famine-related deaths by the end of the decade and reducing starvation and widespread chronic hunger, especially among children, women, and the aged. It also called for the total elimination of inadequate sanitation and poor hygiene, including unsafe drinking water. Governments were urged to promote national plans of action based on the strategies developed at the conference and to allocate the financial and human resources needed to implement the necessary programs. In its report, the conference referred to the nutritional goals set by the Fourth United Nations Development Decade and the World Summit for Children.

In 1995, WHO reported that 31% of the world's children under the age of five who live in developing countries were under-weight. A 1994 report urged member nations to implement the International Code of Marketing of Breast-milk Substitutes, adopted by the WHA in 1981, to protect women in developing world from being manipulated into feeding their infants breast-milk substitutes, a practice which had been shown to put infants at risk. A wide range of illnesses and nutrition-related disorders are prevented by breast-feeding children. WHO considers direct advertising of infant formula to mothers with infants in the first four to six months of life singularly inappropriate. The 1994 report stated that large sums were being spent misguidedly to provide breast-milk substitutes to the countries of Central and Eastern Europe within the context of food aid programs. The report noted that an adequate diet is more crucial in infancy than at any other time of life because infants have a high nutritional requirement in relation to body weight. Faulty nutrition during the first months has been proved to influence future health and development.

At the end of the century, WHO reported that overall progress in reducing protein-energy malnutrition among infants and young children was "exceedingly slow," and that the year-2000 goal of a 50% reduction in 1990 prevalence levels would not be met. This projected goal aimed at reducing global malnutrition by only 14.3% (89.8 million) in malnourished children under 5 years of age. In the year 2000, WHO reported an estimated 26.7% of the world's children under age 5 (149.6 million children) were still malnourished when measured in terms of weight for age. Nevertheless, this clearly represented significant progress when compared with the 31% who were underweight in 1995 and the 37.4% (accounting for 175.7 million children) who were malnourished in 1980. In 2002, 150 million children (26.7%) are underweight while 182 million (32.5%) are stunted. Geographically, more than 70% of children who suffer from protein malnourishment live in Asia, 26% in Africa and 4% in Latin America and the Caribbean.

Rehabilitation of the Disabled

Since the early 1950s, WHO has had a program for rehabilitation of the disabled. The program was initially set up to increase awareness of the problems faced by war veterans and to stimulate governments to provide increased services for this group.

During the 1970s, the program was reoriented to promote rehabilitation in developing countries. A new policy was accepted by the World Health Assembly in 1976, making rehabilitation part of primary health care services. WHO then developed a whole series of teaching-training materials to be used at the community level. All of this material has been published in a manual entitled Training in the Community for People with Disabilities .

The basic idea governing the program is that training for disabled people can be successfully given by family members, under the guidance and supervision of a local health worker. Referral services are needed for some 30%, mostly for short-term interventions. The program stresses the importance of involving the family and community in rehabilitation.

New plans concentrate on development of the personnel needed for providing community-based rehabilitation services at the community and district levels. The aim is to broaden the population coverage so that most people with disabilities will have access to at least the essential services.

Occupational Health

WHO's Occupational Health Program has four main aims: (1) health protection of the underserved working populations who constitute the bulk of the economically productive persons in developing countries; (2) strengthening of general health services through the application of occupational health technologies and approaches; (3) workers' participation in their health care delivery systems; and (4) development of occupational health science, technology, and practice.

The program incorporates identification and control of "work-related diseases," recognition of neuro-behavioral changes from occupational exposure to health hazards, control of occupational impairment in reproductive functions and other delayed effects and of adverse occupational psychosocial hazards, and the application of ergonomics as a factor in health promotion. WHO cooperates with countries in the development of their institutional framework for the health care of working people. Special attention is given to occupational health concerns of employed women, children, the elderly, migrant workers, and other groups.

Environmental Health

Safe drinking water, proper community sanitation (sewage disposal systems), rural and urban development, and housing standards are among the priorities of WHO's environmental health program. Many of WHO's projects in this area are carried out in collaboration with other United Nations agencies, including UNICEF, the World Bank, UNDP, and FAO.

Beginning in 1986, WHO sponsored a series of international consultations on cost recovery in community water supply and sanitation. Its Guidelines for Drinking-water Quality have been applied in developing countries. WHO has studied the technical aspects of wastewater reuse in agriculture and collaborated with UNEP, the World Bank, and FAO in formulating guidelines and defining strategies for safe wastewater reuse in agriculture.

WHO is also concerned with prevention and control of environmental pollution, and has produced technical manuals on the disposal of hazardous waste. The WHO/ILO/UNEP International Programme on Chemical Safety (IPCS) was established in 1980. It provides information on the risks to human health and the environment of potentially toxic chemicals, and guidance in the safe use of chemicals. The IPCS was designated by UNCED as the nucleus for international cooperation on environmentally sound management of toxic chemicals.

In 1992, the WHO Commission on Health and the Environment published Our Planet, Our Health , one of several documents that served as the basis of WHO's contribution to the United Nations Conference on Environment and Development (the Earth Summit) held in Rio de Janeiro in June 1992. The WHO endorsed a new global strategy for health and environment based on the Commission's recommendations. In August and September 2002, the UN hosted a World Summit on Sustainable Development (WSSD) in Johannesburg, South Africa, as a 10-year follow-up to the 1992 Earth Summit. The WHO's contributions to WSSD focused on both overall, long-term benefits for social, economic, and environmental development that resulted from investment in people's health, and on the health aspects of specific issues on the summit's agenda. Its emphases included:

• The positive impact of health both as a good in its own right and as a means of advancing economic development and poverty reduction.
• The direct impact of environmental degradation and unsustainable use of natural resources on people's health, as well as the indirect impact on the livelihoods (and, therefore, health) of the poor.
• The need to assess the impact on people's health of development policies and practices.
• The importance of partnerships and alliances as a means of addressing threats to health and promoting sustainable development.

In the interest of helping member states pursue programs of sustainable development and healthy environments, WHO set up the Protection of the Human Environment (PHE) program and web site http://www.who.int/peh/ . To organize its efforts, the WHO has distinguished between environmental threats to human health that are "traditional hazards" (those associated with lack of development) and threats that pose "modern hazards" (those associated with unsustainable development). Traditional hazards, which are related to poverty and lack of development, include lack of access to safe drinking-water; inadequate basic sanitation in the household and community; food contamination with pathogens; indoor air pollution from cooking and heating; inadequate solid waste disposal; occupational injury hazards in agriculture and cottage industries; and natural disasters, including floods, droughts, and earthquakes. Modern environmental hazards, which are related to excessive development (development without regard to adequate health and the environment and which requires the unsustainable consumption of natural resources) include water and air pollution; hazardous waste accumulation and disposal; chemical and radiation hazards; deforestation and land degradation; climate change; and depletion of the ozone layer.

WHO's environmental health activities include risk assessment and research, which help provide evidence for legislators to formulate laws and standards. In this work, WHO collaborates with national health and environment authorities. WHO also supports analysis of the current environmental situation and trends to assist in the development of international initiatives to combat hazards that cross national boundaries.

Mental Health

In 2002 the WHO estimated that approximately 450 million people are affected by mental, neurological, or behavioral problems at any given time. The vast majority of these people are believed to suffer from depression, anxiety disorders, schizophrenia, dementia, and epilepsy. One-third may be affected by more than one neuropsychiatric ailment and three-quarters of those affected live in developing countries.

In the 1990s World Health Organization substantially expanded its investment in mental health; the Department of Mental Health represented one of its major arms for this purpose. The mission of the department was to mainstream mental health within the UN system and the health sector of its member states; to increase parity between physical and mental health, and between the rights of those affected by mental problems and those not affected; to design effective mental health policies promoting social cohesion; and to identify, disseminate, and implement cost-effective interventions.

In 2000, the Department of Mental Health was merged with the Substance Abuse Department to form the Department of Mental Health and Substance Dependence. With respect to mental health, the department has two broad objectives: closing the gap between what is needed and what is currently available to reduce the burden of mental disorders worldwide, and promoting mental health. The department leads the mhGAP (mental health Global Action Programme) focusing on forging strategic partnerships that will enhance countries' capacity to address the stigma and burden of mental disorders and promote the mental wellbeing of populations. Over 100 centers around the world collaborate with the WHO in pursuing mental health objectives.

A number of international collaborative studies have been sponsored and coordinated by WHO. These have focused on the form and course of mental disorders in different cultures, the development of prevention and treatment methods, the operation of mental health services, and psychosocial aspects of health and health care. International exchange of information is fostered through publications, training courses, seminars, and networks of collaborating research and training centers in some 40 countries.

The mental health program also includes projects concerned with the development of standardized procedures, diagnostic classifications, and statistics necessary for an improved mental health information system and collaboration in mental health research, and a major program concerned with the prevention and treatment of alcohol and drug dependence.

In the late 1980s WHO launched an Initiative of Support to People Disabled by Mental Illness, intended to facilitate the dissemination of information about good practice in community services for people with chronic mental illnesses. The initiative seeks to reduce the disabling effects of chronic mental illness and highlight social and environmental barriers which hinder treatment and rehabilitation. The Initiative sought to involve the patient in decisions affecting his or her care. The prerequisites to that involvement were considered to be: the right to be empowered; the right to representation; the right to have access to one's own medical records; the right to be free of stigmatizing labels.

In 1989, WHO began a major study to investigate the types and frequency of psychological problems in 14 countries. By 1992, it had screened 25,000 patients aged 18 to 65. The patients were classified in different categories according to the symptoms, and their progress was followed for a one-year period.

In December 1991, the United Nations General Assembly, in its resolution 46/119, approved the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care. This gave mental health advocacy groups a tool to publicize their views on empowerment. The Initiative has produced publications, including Schizophrenia: Information for Families , which has been translated into 15 languages.

WHO considers the promotion of mental health—that is, the improvement of the position that mental health occupies in the scale of values of individuals, communities, and societies—as one of its fundamental tasks and as being essential for human development and the quality of life.

D. Pharmaceuticals

Pharmaceutical Products in International Commerce

Since 1964, WHO has studied ways of ensuring that all drugs exported from a country comply with its domestic drug quality requirements. A Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce was adopted by the World Health Assembly in 1969, and a revised version in 1975. According to the scheme, in which about 124 countries are participating, the health authorities of the exporting countries provide a certificate that the product is authorized for sale in the exporting country and that the plant in which the product is produced is subject to regular inspection to ensure that it conforms to good practices of manufacture and quality control as recommended by WHO. Also under the scheme, the importing country may request from the authorities of the exporting country additional information on the controls exercised on the product. In addition to the product certificate issued by the competent authority of the exporting country, batch certificates, stating that the quality of the batch complies with quality specifications and indicating the expiration date and storage conditions, may be issued either by the competent authority of the exporting country or by the manufacturer.

International Biological Standardization

Biological substances cannot be characterized entirely by physical or chemical means. Their activity can be controlled only by tests in which laboratory animals, microorganisms, cell cultures, or antigen-antibody reactions are used. Such assays use biological reference materials which have previously been determined, usually under the form of an international unitage system, by calibration against appropriate international reference materials.

Much work in this field was done under League of Nations auspices. By 1945, 34 international biological standards had been established for such substances as antibiotics, antibodies, antigens, blood products and related substances, and hormones. Since then, WHO has enlisted the collaboration of more than 100 laboratories to conduct international collaborative studies, and there are now more than 200 international standards available to national control authorities throughout the world.

The work on biological standardization has expanded considerably and comprises a number of additional activities, including the establishment of international reference reagents, mainly for the purpose of diagnosis and identification. Furthermore, in order for manufacturers and national control authorities to achieve the production of biological substances which are safe and potent, international requirements on production and control have been prepared and are published in the Technical Report Series, released each year by the WHO Expert Committee on Biological Standardization. Such requirements are kept up to date in the light of developing technology. By the end of 1999, 48 sets of international requirements had been published. In addition, guidelines have been published on such subjects as the setting up of biological standards, the testing of kits used for the assay of biological substances, and the use of interferon therapy.

A complete list of international standards and international reference reagents is published by WHO in Biological Substances.

Pharmaceutical Quality Control

International Pharmacopoeia. Attempts to establish internationally agreed-upon specifications for therapeutic agents have been made since the 1850s. By 1910, limited agreements were reached concerning certain potent drugs. Since 1951, WHO has published the International Pharmacopoeia, which provides internationally acceptable standards for the purity and potency of pharmaceutical products moving in international commerce that are available for adoption by member states in accordance with the WHO constitution and resolutions of the World Health Assembly.

The first edition, consisting of two volumes and a supplement, was issued between 1951 and 1959. The second edition was published in 1967; a supplement was added in 1971 and additional monographs in 1972. Work on the third edition, started in 1975, aims to accommodate the needs of developing countries by offering sound standards for the essential drugs. Four volumes were issued in 1979, 1981, 1988, and 1994, and as of December 2002, the fifth volume was in its final stages of preparation.

International Nonproprietary Names for Pharmaceutical Substances. Many pharmaceutical substances are known not only by their nonproprietary, generic, or scientific names but by various trade names as well. In order to identify each pharmaceutical substance by a unique, universally available nonproprietary name, WHO has set up a procedure to select international nonproprietary names for pharmaceutical substances. Such names are published regularly in the WHO Chronicle. By the end of 1987, over 5,400 names had been proposed and published in 48 lists. A ninth cumulative list was published in 1996, and includes over 6,500 names.

WHO Collaborating Center for Chemical Reference Substances. As a further service in the area of drug quality control, the WHO Collaborating Center for Chemical Reference Substances was established in Sweden, at the Apotekens Centrallaboratorium, in 1955. Its function is to collect, assay, and store international chemical reference substances and to make them available free to national and nonprofit laboratories and institutes and, for a nominal fee, to commercial firms. About 140 chemical reference substances needed for tests and assays described in the International Pharmacopoeia are available.

Good Practices in the Manufacture and Quality Control of Drugs. To assist member states with technical advice on adequate control processes in drug manufacture, the World Health Assembly, in 1969, recommended the requirements in a publication entitled Good Practices in the Manufacture and Quality Control of Drugs. A revised text was adopted in 1975 by the assembly. Today it is published in two volumes as Quality Assurance of Pharmaceuticals: A Compendium of Guidelines and Related Materials. The text contains requirements pertaining to personnel, premises, and equipment of manufacturing establishments and general hygienic and sanitation measures. Special requirements pertain to raw materials, manufacturing operations, and labeling and packaging of products. The organization and duties of a quality-control department and a quality-control laboratory are specified.

Essential Drugs. As early as 1975, the WHA had received reports of the experiences of a few countries who had adopted schemes of basic or essential drugs. The purpose was to help people in developing countries whose basic health needs could be met through the existing supply system by giving them access to the most necessary drugs. The WHA recommended that member states draw up national drug policies to ensure that the most essential drugs were available at a reasonable price, and to stimulate research and development to produce new drugs adapted to the real health requirements of developing countries. There was recognition that developing countries could not afford to waste scarce resources on drugs which either did not meet majority needs, or which were priced at a level which their societies could not afford.

In 1977, a WHO committee of experts met to determine how many drugs were really needed to ensure a reasonable level of healthcare for as many people as possible. It was determined that, in country after country, a surprisingly uniform picture of drug selection emerged. At the village health post or dispensary level, 10 to 15 drugs meet immediate needs. At the health center level, where the diagnostic and local facilities are better and the staff more highly trained, about 30 to 40 drugs will suffice for 80% to 90% of all complaints. District and provincial hospitals may need around 100 to 120 drugs, and the large referral and teaching hospitals the full range of 200 to 400. The committee's first Model List of Essential Drugs appeared in 1977 and contained some 200 items. By 1994 the list numbered 270 drugs. All of the drugs and vaccines on the list were of proven safety and efficacy, and possessed well understood therapeutic qualities. Most were no longer protected by patent and could be produced in quantity at reasonable cost. The Model List is revised every two years in order to respond to evolving needs and pharmaceutical advances. The list is not meant to be definitive, but to serve as a guideline for each country to pick and choose from in order to adopt a list of essential drugs according to its own priorities. The 11th edition was published in 1999.

In 1981, WHO launched its Action Programme on Essential Drugs to help narrow the list of drugs that would be essential for small medical units in developing countries. This program assists countries in developing their own legislation and methods of financing comprehensive drug programs. It also assists them in implementing the quality control monitoring regimes mentioned above. The Action Programme also provides support for training personnel in the areas of drug management and rational use. It supports national and regional seminars at which hundreds of health staff from countries throughout the world receive practical training. In the area of research, the program encourages research aimed at filling gaps in existing knowledge about the best means of selecting, procuring, and distributing drugs. This research seeks to discover how providers make decisions on which drugs to prescribe, or how and why patients use—or fail to use—medicines. This research has direct bearing on the ways in which vital medicines can be made available and accessible to the greatest number of people. More than 100 countries have adapted the Model List to match their own patterns of disease and financial resources.

E. Research Promotion and Development

Through its advisory committees on medical research—one for each of the six WHO regions and one at the global level—WHO provides guidelines for research planning, execution, and implementation in health programs directly linked to national priorities. The committees also offer an appropriate forum for the discussion of national and regional experiences and for the detailed formulation of scientific and technological policies in the field of health. Research programs and activities are developed in close coordination with medical research councils or analogous bodies, with particular emphasis on the strengthening of managerial capacities at all levels.

WHO's coordinating role in research calls for the development of a system for the exchange of scientific information and the enlistment of the collaboration of groups of scientists and research workers in various areas on solving key problems and developing methods for most effectively combining their efforts.

Over the years, more than 1200 institutions with the necessary expertise and facilities have been designated by WHO as "WHO Collaborating Centers." WHO also designates expert advisory panels. Financial assistance is sometimes provided by WHO through technical services agreements, partially offsetting the much larger expenses borne by the centers themselves.

In order to increase the research potential of member countries, WHO has developed a program to train research workers. The duration of grants varies, but as far as possible, they are made sufficiently long to permit the candidate to gain an adequate knowledge of methods and techniques and, very often, to carry out, under supervision, a specific piece of research.

Communication among scientists is also promoted. A scientist from one country is enabled to visit scientists in other countries for a period of up to three months, thus facilitating personal contact and the exchange of ideas.

WHO promotes meetings, symposia, seminars, and training courses in special techniques, bringing together scientists from various parts of the world. Reports of such meetings are circulated, when appropriate, to the scientific community.

F. Health Personnel Development

WHO's role in health personnel development is to collaborate with member states in their efforts to plan, train, deploy, and manage teams of health personnel made up of the numbers and types that are required (and that they can afford) and to help ensure that such personnel are socially responsible and possess appropriate technical, scientific, and management competence.

WHO is attempting to raise the political, economic, and social status of women as health care providers in the formal and informal health care system and in the community and to ensure that they receive the education, training, and orientation to enable them to expand the scope and improve the quality of the health care that they provide to themselves, each other, their families, and other members of the community.

Members of the World Health Organization
(as of 2002)

Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyz Republic
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Federated States of)
Monaco
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Moldova
Romania
Russian Federation
Rwanda
St. Kitts and Nevis
St. Lucia
St. Vincent and the Grenadines
Samoa
San Marino
São Tomé and PríFncipe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tajikistan
Thailand
The Former Yugoslav
Republic of Macedonia
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United Republic of Tanzania
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Yugoslavia
Zambia
Zimbabwe
ASSOCIATE MEMBERS
Puerto Rico
Tokelau

Promotion of community-oriented educational programs with team and problem-based methods of teaching/learning is another approach. The programs are designed to prepare personnel to perform tasks directly related to identified service requirements of specific concern to the country. Appropriate teaching and learning materials, including those for self-teaching and audiovisual purposes, adapted to different cultures and languages, are promoted for all categories of health personnel.

Fellowships occupy an important place in WHO's program as one of the ways to provide opportunities for training and study in health matters which are not available in the fellow's own country and for the international exchange of scientific knowledge and techniques relating to health. WHO encourages the nomination, selection, and evaluation of fellows based on and determined by a member state's personnel development policy, in line with its national policy for health development, so that fellowships can contribute to the training of the type and amount of personnel needed to achieve the global target of "health for all." WHO awards fellowships preferably to candidates who will be directly involved in primary health care programs.

In many countries, however, the problem is no longer one of shortage of health professionals, but rather of establishing or maintaining the right balance between them to ensure that the necessary knowledge and skills are available. WHO is sponsoring studies to develop information systems and methods to help countries achieve this balance.

Nursing. The WHA, in 1992, recommended that each country develop a national action plan for nursing. A global advisory group on nursing and midwifery was established by the 45th WHA, and held its first meeting in 1992. It recommended that, as the largest group of health personnel in any country, nursing and midwifery be declared a priority area for WHO action. A WHO study group on nursing beyond the year 2000 convened in July 1993. It adopted the Nursing Declaration of Alma-Ata, which recognizes that a multiprofessional, multidisciplinary approach is needed to prepare healthcare providers to work in a rapidly changing environment. As a starting point, every health ministry was urged to establish a position of chief nurse, with appropriate staff and budget.

G. Public Information and Education for Health

To integrate health education and information for health, WHO established the Division of Public Information and Education for Health. Its major tasks, in close cooperation with all regions, are to work with governments in developing coordinated information/education programs aimed at promoting healthy behavior and increasing self-reliance among individuals and communities, and to work with technical units in planning, developing, and implementing an information/education component in their programs.

The need for promotion, advocacy, and greater public awareness of health issues is a recurring theme in virtually all WHO programs. WHO considers health education as the sum of activities that will encourage people who want to be healthy to know how to stay healthy, to do what they can individually and collectively to maintain health, and to seek help whenever it may be needed.

WHO has developed many computerized information resources over the years, including WHOLIS, the WHO library information system, which is available on diskette and on the Internet. WHODOC, a regular listing of new WHO publications and documents is also available on diskette and on the Internet. See United Nations Databases for a descriptive listing of WHO's computerized databases.

H. Health Legislation

While WHO is aware of the importance of health and related legislation to the delivery of personal and environmental health services in countries, it has no mandate to propose model legislation. On the other hand, it recognizes member states' need for relevant and timely information. WHO is mandated to maintain an awareness of all significant new laws and regulations in the field of health, and to disseminate information thereon as rapidly as possible. The main vehicle for information transfer is its International Digest of Health Legislation which is now issued only in an electronic form. A demand for information on HIV/AIDS legislation prompted WHO to develop a computerized database that covers relevant legislation as well as literature on the legal, ethical, and judicial aspects of AIDS. Data on other subjects, such as legislation to combat smoking, have also been computerized.

In February 1994, the First International Conference of Medical Parliamentarians was held in Bangkok, organized by the Asian Forum of Parliamentarians on Population Development and the International Medical Parliamentarians Organization in close cooperation with WHO. More than 80 medical parliamentarians from 33 countries attended the conference to discuss five specific areas: environmental health, population and development; narcotics drug abuse; organ transplantation; public health and development; and maternal and child health and AIDS. The conference adopted the Bangkok Declaration and Call for Action which set forth goals and priorities for the establishment of national legislation in the five subject areas.

The International Medical Parliamentarians Organization (IMPO) was admitted into official relations with WHO in 1995, joining the ranks of the numerous NGOs that have working relationships with WHO. In 1999, IMPO had individual members in more than 30 countries, including many developing nations.