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OMS La Salud Mental en El Mundo Informe 1998 Ingles
OMS La Salud Mental en El Mundo Informe 1998 Ingles
OMS La Salud Mental en El Mundo Informe 1998 Ingles
World Health
Report
1998
The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part
or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization,
Geneva, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for
new editions, and reprints and translations already available.
ii
Contents
Chapter 1
Leading and responding 9
Chapter 2
Measuring health 39
Chapter 3
Health across the life span 61
Chapter 4
The changing world 113
Chapter 5
Achieving health for all 139
Chapter 6
WHO worldwide 165
Chapter 7
Global partnerships for health 191
Chapter 8
Health agenda for the 21st century 201
Annex 1
Members and Associate Members of WHO 213
Annex 2
Statistics 215
Index 233
iii
Synopsis of the report
iv
Message from the Director-General
T
he desire for a healthier and Issued as the World Health Or-
better world in which to live ganization marks its 50th anniversary,
our lives and raise our children The World Health Report 1998 offers
is common to all people and all gen- a cautiously optimistic vision of the
erations. Now, as we near the end of future up to the year 2025. It gives us
one century and enter the next, our hope that longer life can be a prize
past achievements and technological worth winning.
We are slowly learning advances make us more optimistic Based on a review of health trends
about our future than perhaps at any in the past 50 years, it finds that over-
stage in recent history. all, remarkable improvements in health
one of lifes most Despite being threatened by two have been due to socioeconomic devel-
devastating world wars in the first half opment, the wider provision of safe
of this century, and by many other con- water, sanitation facilities and personal
important lessons: flicts and catastrophes in the second, hygiene, and the establishment and
humanity has, in general, not merely expansion of national health services.
survived; it has thrived. Today, at least Major infectious diseases, such as
not just how to live 120 countries (total population above poliomyelitis, leprosy, guinea-worm
5 billion) have a life expectancy at birth disease, Chagas disease and river
longer, but also of more than 60 years; the global aver- blindness, are steadily being defeated.
age is 66 years compared to only 48 There have been spectacular advances
years in 1955; it is projected to reach in the development of vaccines and
how to stay longer 73 years in 2025. medicines, and countless other inno-
However, one of the main mes- vations in the investigation, diagnosis
sages of The World Health Report and treatment of illness, in the reduc-
in good health with 1997 was the need to recognize that tion of disability and in rehabilitation.
increased longevity without quality of Tragically, however, while average
life is an empty prize that health ex- life expectancy has been increasing
less dependence pectancy is more important than life throughout the 20th century, 3 out of
expectancy. It is therefore particularly 4 people in the least developed coun-
encouraging to show evidence in this tries today are dying before the age
on others. years report of remarkable declines in of 50 the global life expectancy fig-
disability over periods of time among ure of half a century ago. This year,
older people in some populations. 21 million deaths 2 out of every 5
In an era of global population age- worldwide will be among the un-
ing, this is not just good news for the der-50s, including 10 million small
individuals concerned and the socie- children who will never see their fifth
ties in which they live. It may be a vi- birthday though most children world-
tal signal for us all. It suggests that we wide are now immunized against
are slowly learning one of lifes most major childhood killers. Over 7 mil-
important lessons: not just how to live lion will be men and women in what
longer, but also how to stay longer in should be some of the best and most
good health with less disability, and productive years of their lives. Reduc-
therefore, less dependence on others. ing these premature deaths is one of
v
the greatest challenges facing human- and poor, and keeping it there. It is
ity at the dawn of the 21st century. time to realize that health is a global
There are others challenges. For issue; it should be considered as an
while health globally has steadily im- essential component of the continu-
proved over the years, great numbers ing globalization process that is re-
of people have seen little if any im- shaping our world; it should be in-
provement at all. The gaps between cluded in the growing interaction be-
the health status of rich and poor are tween countries that currently exists
at least as wide as they were half a cen- in terms of world trade, services, for-
tury ago, and are becoming wider still. eign investment and capital markets.
The prime concern of the inter- With the help of instant interna-
national community must be the tional communications and informa-
plight of those most likely to be left tion technologies, and global surveil-
furthest behind as the rest of the lance systems to detect problems,
world steps confidently into the fu- prepare for them and respond to
ture. These are the many hundreds them, a wonderful opportunity now
of millions of men, women and chil- exists to build the new international
dren still trapped in the past by the partnerships for health, based on so-
grimmest poverty. They live mainly in cial justice, equity and solidarity, that
the least developed countries, where the world of the 21st century will so
the burdens of ill-health, disease and urgently need.
inequality are heaviest, the outlook is They are partnerships involving all
bleakest, and life is shortest. countries, their governments, their civil
Worldwide, the majority of pre- societies, and their individuals. All can
mature deaths are preventable. At be partners who are willing to share and
least 2 million children a year die from exchange the life-enhancing informa-
diseases for which there are vaccines. tion and technology that is already at
The report gives encouraging evi- the fingertips of the rich but as yet be-
dence that premature deaths among yond the reach of the poor. Such a po-
adults, too, can be significantly re- litical vision is fundamental to ensure a
duced. Deaths from heart disease participatory approach to peace and
have been dramatically reduced in development at local, national and in-
many countries which are experienc- ternational levels and thus enhance the
ing a transition from high incidence welfare of the individual and society.
of circulatory diseases to low inci- The progress and achievements of
dence, mainly due to the adoption of the past 50 years are solid foundations
healthier lifestyles. It is imperative for a healthier and better world. It is
that such a favourable shift, condu- already time to build on them. Life
cive to further reductions in the inci- in the 21st century could and should
dence of these diseases, should be be better for all. We can pass no
sustained and if possible accelerated. greater gift to the next generation
Infectious diseases, meanwhile, than a healthier future. That is our
remain leading causes of premature vision. Together, the people of the
death among adults in much of the world can make it a reality.
developing world. Reducing these
tolls depends largely on the political
will and commitment of individual
governments, and the active support
of the international community. Hiroshi Nakajima, M.D., Ph.D.
This means putting health high Director-General
on the agenda of all countries, rich World Health Organization
vi
Introduction
Introduction
T
he 21st century offers a bright people a year are dying before the age
vision of better health for all. of 50, while average life expectancy
It holds the prospect not has risen to 66 years. Ten million of
merely of longer life, but superior these deaths are among children un-
quality of life, with less disability and der 5 years; 7.4 million others are
The most important disease. As the new millennium ap- among adults aged 20-49.
proaches, the global population has Even so, the most important pat-
never had a healthier outlook. tern of progress now emerging is an
pattern of progress Weighing the evidence of the past unmistakable trend towards healthier,
and the present, The World Health longer life. Supported by solid scien-
now emerging is an Report 1998 shows that humanity has tific evidence of declines in disability
many good reasons for hope in the among older people in some
future. Such an optimistic view must populations, this has considerable
unmistakable trend be tempered by recognition of some implications for individuals and for
harsh realities. Nevertheless, unprec- societies.
edented advances in health during the The explanation for this trend lies
towards healthier, 20th century have laid the founda- in the social and economic advances
tions for further dramatic progress in that the world has witnessed during
the years ahead. the late 20th century advances that
longer life. This report provides the latest ex- have brought better living standards
pert assessment of the global health to many, but not all, people. The
situation, and uses that as a basis for world saw a golden age of unparal-
projecting health trends to the year leled prosperity between 1950 and
2025. Examining the entire human 1973, followed by an economic slump
life span, and sifting data gathered in that lasted 20 years. A global eco-
the past 50 years, it studies the well- nomic recovery has been under way
being of infants and children, adoles- since 1994. The long-term benefits
cents and adults, older people and the are now becoming apparent. While
oldest old, and identifies priority ar- they are most evident in the industri-
eas for action in each age group. alized world, they are slowly but
Womens health is given special em- surely materializing in many poorer
phasis. The future of human health countries, too.
in the 21st century depends a great For example, food supply has
deal on a commitment to investing in more than doubled in the past 40
the health of women in the world to- years, much faster than population
day. Their health largely determines growth. Per capita GDP in real terms
the health of their children, who are has risen by at least 2.5 times in the
the adults of tomorrow. past 50 years. Adult literacy rates have
The reports most disturbing find- increased by more than 50% since
ing is that, despite increasing life ex- 1970. The proportion of children at
pectancy, two-fifths of all deaths in the school has risen while the proportion
1
The World Health Report 1998
of people chronically undernourished sanitation facilities. Most of the
has fallen. worlds children are now immunized
These trends are changing the against the six major diseases of child-
world. Without question, the world of hood measles, poliomyelitis, tuber-
2025 will be significantly different culosis, diphtheria, pertussis and
from todays, and almost unrecogniz- neonatal tetanus.
able from that of 1950. The stunning During the same period there
technological advances of recent have been steady and sometimes
years, particularly in global telecom- spectacular advances in the control
munications, have made the planet and prevention of other diseases, the
seem smaller than ever before. By the development of vaccines and medi-
year 2025, it is likely to seem smaller cines, and countless other medical
still and, with continuing population and scientific innovations. The past
growth, it will certainly be much more decades have seen the final defeat of
crowded. In many ways, the face of smallpox, one of the oldest diseases
In many ways, humanity is being rapidly reshaped. of humanity, and the gradual reduc-
Two main trends increasing life tion in several others, including lep-
expectancy and falling fertility rates rosy and poliomyelitis.
the face of humanity mean that by 2025:
Worldwide life expectancy, cur- Crossing the threshold
is being rapidly rently 66 years, will reach 73 years
a 50% improvement on the 1955 Together, these and related achieve-
average of only 48 years. ments should help humankind to step
reshaped. The global population, about 5.8 confidently across the threshold into
billion in 1997, will increase to the new century. However, the future
about 8 billion. Every day in 1997, will pose many new as well as con-
about 365 000 babies were born, tinuing challenges.
and about 140 000 people died, The war against ill-health in the
giving a natural increase of about 21st century will have to be fought
220 000 people a day. simultaneously on two main fronts:
There will never have been so infectious diseases and chronic,
many older people and so relatively noncommunicable diseases. Many
few young ones. developing countries will come under
The number of people aged over greater attack from both, as heart dis-
65 will have risen from 390 million ease, cancer and diabetes and other
in 1997 to 800 million from 6.6% lifestyle conditions become more
of the total population to 10%. prevalent, while infectious illnesses
The proportion of young people remain undefeated. Of this latter
under 20 years will have fallen group, HIV/AIDS will continue to be
from 40% in 1997 to 32% of the the deadliest menace.
total population, despite reaching This double threat imposes the
2.6 billion an actual increase of need for difficult decisions about the
252 million. allocation of scarce resources. Expe-
These demographic trends, which rience shows that reduced spending
have profound implications for hu- on controlling infectious diseases can
man health in all age groups, follow cause them to return with a venge-
on the many positive changes that ance, while globalization particu-
have occurred in the past 50 years. larly expanding international travel
More people than ever before now and trade, including the transporta-
have access to at least minimum tion of foodstuffs increases the risks
health care, safe water supplies and of their global spread. At the same
2
Introduction
time, the stealthy onset of chronic deaths among children under 5
conditions also saps a nations 97% of them in the developing
strength. This trend will increasingly world, and most of them due to
be the main focus of attention in in- infectious diseases such as pneu-
dustrialized countries which, how- monia and diarrhoea, combined
ever, must not lower their guard with malnutrition.
against infectious diseases. Most of these under-5 deaths are
The past few decades have seen preventable. At least 2 million a
the growing impact on health of pov- year could be prevented by exist-
erty and malnutrition; widening ing vaccines.
health inequalities between rich and Some 25 million low-birth-weight
poor; the emergence of new dis- babies are born every year. They
eases such as HIV/AIDS; the grow- are more likely to die early, and
ing problem of antibiotic-resistant those who survive may suffer ill-
infections; and the epidemic of to- ness, stunted growth or other
bacco-related diseases. health problems, even as adults. HIV/AIDS could
These are only some of the prob- While most premature and low-
lems representing the unfinished birth-weight babies are born in the
agenda of public health actions at the developing world, many born in
reverse some of
end of one century and requiring ur- industrialized countries owe their
gent action at the beginning of the survival to high-technology the major gains
next. neonatal care. Such care may have
This report looks at the health increasingly complex ethical impli-
implications for all age groups in- cations. achieved in child
fants and small children under 5; Tomorrows small children face a
older children of school age and ado- new morbidity of illnesses and
lescents (5-19 years); adults (20-64 conditions that are linked to social health over
years); and older people (65 and and economic changes, including
over). Some of the main findings of rapid urbanization. These include
the report, as they apply to each age neglect, abuse and violence, espe- the last 50 years.
group, are summarized below. cially among the growing numbers
of street children.
Infants and small children One of the biggest hazards to chil-
dren in the 21st century will be the
Spectacular progress in reducing continuing spread of HIV/AIDS.
under-5 mortality achieved in the In 1997, 590 000 children aged un-
past few decades is projected to der 15 became infected with HIV.
continue, and could even acceler- The disease could reverse some of
ate. There were about 11 million the major gains achieved in child
deaths among children under 5 in health over the last 50 years.
1995 compared to 21 million in Better prevention and treatment of
1955; there will only be 5 million some hereditary diseases in small
deaths in 2025. children is likely.
The infant mortality rate per 1000
live births was 148 in 1955; 59 in Older children and adolescents
1995; and is projected to be 29 in
2025. Traditionally regarded as enjoying the
The under-5 mortality rates per healthiest phase of life, these young-
1000 live births for the same years sters have tended to receive insuffi-
are 210, 78 and 37 respectively. cient public health attention. But to-
In 1997, there were 10 million day theirs is a prime time for health
3
The World Health Report 1998
promotion to encourage them to es- Adults
tablish healthy patterns of behaviour
that will influence their development Globally, adults are now surviving
and health in later years. longer, largely because during the
There will be an even greater need past half century, when they were
than at present for education and children, epidemics of infectious dis-
advice on unhealthy diet, inad- eases such as tuberculosis and respi-
equate exercise, unsafe sexual ac- ratory disease were being better con-
tivity and smoking, all of which trolled. The continuing gains in the
provoke disease in adulthood but survival of infants and young children
have their roots in these early means that the adult population is
formative years. increasing.
Research suggests that stress, poor Currently, just over half the popu-
in the coming years by such poten- of working age will be vitally im-
children means that tially deadly rites of passage as portant if this age group is to sup-
violence, delinquency, drugs, alco- port growing numbers of depend-
hol, motor-vehicle accidents and ants, both young and old.
the adult population sexual hazards. For many, espe- However, more than 15 million
cially those growing up in poor ur- adults aged 20-64 are dying every
ban areas, adolescence will repre- year. Most of these deaths are pre-
is increasing. sent the most dangerous years of ventable.
life. Among the most tragic of these
Sexuality and sexual activity, key as- deaths are those of 585 000 young
pects of affirming maturity and women who die each year in preg-
adulthood, are becoming more nancy or childbirth.
dangerous due to HIV and other 2-3 million adults a year are dying
4
Introduction
the future because of the spread of Cases of and deaths from lung can-
strains of pneumonia, tuberculosis and cer and colorectal cancer will in-
malaria that are resistant to the most crease, largely due to smoking and
powerful medicines. Steady increases unhealthy diet. Lung cancer deaths
in cases of and deaths from tubercu- among women will rise in virtually
losis are evidence of this trend. all industrialized countries.
The future of infectious disease Stomach cancer will become less
control is likely to lie with vaccines common, mainly because of im-
rather than drugs. proved food conservation, dietary
In general, noncommunicable dis- changes and declining related in-
eases such as coronary heart dis- fection.
ease, cancer, diabetes and mental Cervical cancer is expected to de-
disorders are more common than crease further in industrialized
infectious diseases in the industri- countries due to screening; the
alized world. Coronary heart dis- possible advent of a vaccine would
ease and stroke have declined as greatly benefit both developed and Population ageing
causes of death in these countries developing countries.
in recent decades, while death Liver cancer will decrease as a con-
rates from some cancers have
5
The World Health Report 1998
Even in wealthy countries, most disadvantage from the moment of
old and frail people cannot meet birth. Today, girls and women are still
more than a small fraction of the denied the same rights and privileges
costs of the health care they need. as their brothers, at home, at work,
In the coming decades, few coun- in the classroom or the clinic. They
tries will be able to provide spe- suffer more from poverty, low social
cialized care for their large popu- status and the many hazards associ-
lation of aged individuals. ated with their reproductive role. As
Some European countries already a result, they bear an unfair burden
acknowledge that there is insuffi- of disadvantage and suffering, often
cient provision to meet with dig- throughout their lives.
nity the needs of all those over the Global population ageing is result-
age of 75, who currently consume ing in the evolution towards societies
many times more medical and so- which are, for the most part, female.
cial services than those under 75. Yet while women generally live longer
Today, the status Developing countries will face than men, for many of them greater
even more serious challenges, life expectancy carries no real advan-
given their economic difficulties, tage in terms of additional years lived
and well-being of the rapidity with which popu- free of disability.
lations age, the lack of social serv- The status of womens health in
countless millions ice infrastructures, and the decline old age is shaped throughout their
of traditional caring provided by lives by factors over which they have
family members. little if any control. If longer lives for
of women worldwide Many of the chronic conditions of women are to be years of quality, poli-
old age can be successfully de- cies must be aimed at ensuring the
tected, prevented and treated, best possible health for women as
remain tragically low. given sufficient resources and ac- they age. These policies should be
cess to care. geared towards the problems that
Worldwide, circulatory disease is begin in infancy or childhood, and
the leading cause of death and should cover the whole life span,
disability in people over 65 years, through adolescence and adulthood
but there is great potential for pre- into old age.
venting and treating it. Infancy and childhood. The
health of parents, particularly the
Women mother before and during pregnancy,
and the services available to her
Womens health is inextricably linked throughout her pregnancy, especially
to their status in society. It benefits at delivery, are important determi-
from equality, and suffers from dis- nants of the health status of their chil-
crimination. Today, the status and dren. Infants whose health status is
well-being of countless millions of compromised at birth are more vul-
women worldwide remain tragically nerable to various health problems
low. As a result, human well-being in later in life. Girls who are inad-
general suffers, and the prospects for equately fed in childhood may have
future generations are dimmer. impaired intellectual capacity, de-
In many parts of the world, dis- layed puberty, possibly impaired fer-
crimination against women begins tility and stunted growth, leading to
before they are born and stays with higher risks of complications during
them until they die. Throughout his- childbirth. Female genital mutilation,
tory, female babies have been un- of which 2 million girls are at risk
wanted in some societies and are at a every year, or sexual abuse during
6
Introduction
childhood, increase the risk of poor classified as being severely under-
physical and mental health in later weight, and about 450 million suffer
years. from goitre.
Adolescence. Most reproductive Older women. Many millions of
health and family planning pro- women are made old before their
grammes have not paid enough atten- time by the daily harshness and in-
tion to the special needs of adoles- equalities of their earlier lives, begin-
cents. Premature entry into sexual ning in childhood. They experience
relationships, high-risk sexual behav- poor nutrition, reproductive ill-
iour and lack of education, basic health, dangerous working condi-
health information and services all tions, violence and lifestyle-related
compromise the current and future diseases, all of which exacerbate the
well-being of girls in this age group. likelihood of breast and cervical can-
These girls are at increased risk cers, osteoporosis and other chronic
of sexually transmitted diseases, in- conditions after menopause. In old
cluding HIV/AIDS, early pregnancy age poverty, loneliness and alienation Where women have
and motherhood, and unsafe abor- are common.
tion. Adolescent girls are not physi-
cally prepared for childbirth, and are
many pregnancies
much more at risk of maternal death
Health agenda
than women in their twenties. Inad- for the 21sr century the risk of related
equate diet during adolescence can
jeopardize girls health and physical The World Health Report 1998 and
development, with permanent conse- its three predecessors have helped death over the
quences. Iron-deficiency anaemia is create a comprehensive map of the
particularly common among adoles- major issues that have dominated
cent girls. world health in the second half of the course of their lifetime
Adulthood. The consequences of 20th century. The priorities for inter-
poor health in childhood and adoles- national action recommended in
cence, including malnutrition, be- these four reports chart the future for is compounded.
come apparent in adulthood, particu- health action in the 21st century.
larly during the childbearing years. The World Health Report 1995
This time is a particularly dangerous Bridging the gaps, identified poverty
phase in the lives of many women in as the greatest cause of suffering and
developing countries, where health showed the widening health gaps be-
care services, especially reproductive tween rich and poor. It recommended
health facilities, are often inadequate using available resources as effec-
and where society puts pressure on tively as possible and redirecting them
couples to have many children. More to those who need them most.
than 50% of pregnant women in the The World Health Report 1996
developing world are anaemic. Fighting disease, fostering develop-
About 585 000 women die each ment identified three main priorities:
year of pregnancy-related causes. completing the unfinished business of
Where women have many pregnan- eradication and elimination of specific
cies the risk of related death over the diseases; tackling old diseases such
course of their lifetime is com- as tuberculosis and malaria, and the
pounded. While the risk in Europe is problems of antimicrobial resistance;
one in 1400, in Asia it is one in 65, and combating newly-emerging dis-
and in Africa, one in 16. eases.
An estimated 50 million adult The World Health Report 1997
women in developing countries are Conquering suffering, enriching hu-
7
The World Health Report 1998
manity stressed the importance of Increased international coopera-
health expectancy over life expect- tion in health can be facilitated by a
ancy in the context of chronic managed global network making use
noncommunicable diseases. Its main of the latest communication technolo-
recommendation was the integration gies. Global surveillance for the de-
of disease-specific interventions into tection of and response to emerging
a comprehensive chronic disease con- infectious diseases is essential. As a
trol package incorporating preven- result of increased global trade and
tion, diagnosis, treatment, rehabilita- travel, the prevention of foodborne
tion and improved training of health infections in particular is of increas-
professionals. ing importance. Wars, conflicts, refu-
This years report has shown the gee movements and environmental
major developments and achieve- degradation also facilitate the spread
ments in health in the past 50 years of infections as well as being health
and described the economic trends, hazards in themselves.
On the unfinished population trends and social trends Enhancing health potential in
which will influence health in the early the future depends on preventing and
21st century. The third evaluation of reducing premature mortality, mor-
agenda for health, progress in implementation of the bidity and disability. It involves ena-
health for all strategy, carried out in bling people of all ages to achieve over
poverty remains 1997, has shown substantial gains in time their maximum potential, intel-
life expectancy and in infectious dis- lectually and physically through edu-
ease control and reductions in infant cation, the development of life skills
the main item. and under-5 mortality. There have also and healthy lifestyles.
been great improvements in immuni- The implications of healthy age-
zation coverage, as well as in access to ing the physical and mental char-
maternal care (including family plan- acteristics of old age and their associ-
ning services) and to essential drugs. ated problems need to be better
These need to be safeguarded. understood. Much more research is
On the unfinished agenda for required in order to reduce disability
health, poverty remains the main item. among older age groups.
The priority must be to reduce it in Concern for the older members
the poorest countries of the world, and of todays society is part of the
to eliminate the pockets of poverty that intergenerational relationships that
exist within countries. Policies directed need to be developed in the 21st cen-
at improving health and ensuring eq- tury. These relationships, vital for so-
uity are the keys to economic growth cial cohesion, should be based on eq-
and poverty reduction. uity, solidarity and social justice.
Safeguarding the gains already The young and old must learn to
achieved in health depends largely on understand each others differing as-
sharing health and medical knowl- pirations and requirements. The
edge, expertise and experience on a young have the skills and energies to
global scale. Industrialized countries enhance the life quality of their
can play a vital part in helping solve elders. The old have the wisdom of
global health problems. It is in their their experience of life to pass on to
own interests as well as those of de- the children of today and of coming
veloping countries to do so. generations.
8
Leading and responding
Chapter 1
Leading and responding
WHO, 1948-1998 demiological bulletin which was even-
tually incorporated in the Weekly epi-
The origins of WHO demiological record of the League of
Nations (now published by WHO). It
P
ublic health beyond national was not until after the Second World
borders was considered in War that the functions of both bod-
1851 at an international sani- ies were combined to form a new or-
The health of all tary conference held in Paris. Five of ganization able to deal with large epi-
the 12 participating countries signed demics through a coordinated inter-
an international sanitary convention national effort. Meanwhile several re-
peoples was to which was annexed the text of in- gional sanitary bodies were set up, in-
ternational sanitary regulations. After cluding a sanitary council in Egypt,
a succession of international sanitary and an international sanitary office in
considered to conferences, 12 States signed the the Americas, which became the Pan
Rome Agreement in 1907, which pro- American Sanitary Bureau in 1923
vided for the setting up in Paris of an (concerned mainly with combating
be fundamental to the international office of public hygiene yellow fever).
(Office international dhygine In 1945, a United Nations confer-
attainment of peace publique OIHP). Its function was ence was held in San Francisco to
to provide general information to par- consider the possibility of setting up
ticipating countries on public health, an international health organization.
and security especially infectious diseases, while The health of all peoples was consid-
retaining a diplomatic orientation (as ered to be fundamental to the attain-
illustrated by the majority decision ment of peace and security in the
in the world. against restricting its directorship to world. In 1946, a preparatory techni-
a physician). Progress was made on cal commission was instituted, com-
control of the main infectious dis- prising not representatives of States
eases, including yellow fever, cholera, but experts selected on the basis of
malaria and tuberculosis. Activities their technical competence. This
also covered food safety, hospital commission proposed the name
building and administration, school World Health Organization and
health, industrial hygiene, and from suggested that the organization
1909, biological standardization. should be run by three bodies: a
Landmarks in international health are World Health Assembly, an Executive
given in Box 1. Board and a Secretariat (Box 2).
When the League of Nations was The International Health Confer-
formed, there was a proposal to trans- ence, the first international confer-
form the OIHP into the health organ ence to be held under the aegis of the
of the League, but this never hap- United Nations, took place in 1946
pened. The Health Organization of in New York. The 51 Member States
the League of Nations thus existed in- of the United Nations were repre-
dependently in Geneva. The OIHPs sented, as well as 13 non-members
publications included a weekly epi- and various specialized agencies and
9
The World Health Report 1998
nongovernmental organizations.
Box 1. Landmarks in international health Within four and a half weeks, the con-
ference drafted the Constitution, as
1830 Cholera overruns Europe, well as a protocol that brought the
1851 The first International Sanitary Conference is held in Paris to produce Rome Agreement to an end and
an international sanitary convention, but fails. transferred OIHPs duties and re-
1892 The International Sanitary Convention, restricted to cholera, is sponsibilities to the new organization.
adopted. The Constitution expressed clearly
the principles that were to govern the
1897 Another international convention dealing with preventive measures
new organization and went a long way
against plague is adopted.
towards fulfilling the wishes of those
1902 The International Sanitary Bureau, later renamed Pan American Sani- who favoured the creation of a single
tary Bureau, and subsequently Pan American Sanitary Organization, body for world health matters.
is set up in Washington, DC. One recurrent theme in all inter-
1907 LOffice international dhygine publique (OIHP) is established in Paris, national discussions, that of non-
with a permanent secretariat and a permanent committee of senior intervention in internal affairs of
public health officials of Member governments. States, played an important part at the
1919 The League of Nations is created and is charged, among other tasks, conference. WHO was requested to
with taking steps in matters of international concern for the preven- act as the directing and coordinating
tion and control of disease. The Health Organization of the League of authority on international health
Nations is set up in Geneva, in parallel with the OIHP. work, but its assistance to govern-
1926 The International Sanitary Convention is revised to include provisions ments was to be subject to those gov-
against smallpox and typhus. ernments request or acceptance. The
1935 The International Sanitary Convention for aerial navigation comes into World Health Assembly was given au-
force. thority to adopt regulations concern-
1945 A United Nations conference in San Francisco unanimously approves the ing certain technical matters. This was
establishment of a new, autonomous, international health organization. tantamount to investing it with legis-
1946 The International Health Conference in New York approves the Con- lative powers, a measure allowing
stitution of the World Health Organization (WHO). governments to accept international
1948 The WHO Constitution comes into force on 7 April (now marked as sanitary arrangements simultaneously
World Health Day each year). and with minimum delay.
It was agreed that the organiza-
1951 The text of new International sanitary regulations is adopted by the
tion should be open to all States with-
World Health Assembly, replacing the previous International Sanitary
out exception. No provision was made
Conventions.
for expelling a Member State, only to
1969 These Regulations are renamed the International health regulations, suspend the voting rights of those who
covering only cholera, plague, smallpox and yellow fever. fail to meet their financial obligations.
1978 A Joint WHO/UNICEF International Conference in Alma-Ata, adopts
a Declaration on Primary Health Care as the key to attaining the goal WHOs first 30 years
of Health for All by the Year 2000.
1979 A Global Commission certifies the worldwide eradication of smallpox, On 7 April 1948, the Constitution was
the last known natural case having occurred in 1977. accepted by the required number of
1981 The Global Strategy for Health for All by the Year 2000 is adopted by Member States of the United Nations
the World Health Assembly and endorsed by the United Nations Gen- (26). There were 48 Members by the
eral Assembly, which urges other international organizations concerned opening of the First World Health
to collaborate with WHO. Assembly and 55 when it closed a
1988 The World Health Assembly resolves that poliomyelitis will be eradi- month later. Many more Members
cated by the year 2000. subsequently joined the Organiza-
1994 WHOs Executive Board launches reform of the Organization in re- tion, bringing the total to 191 as of
sponse to global change. 1 January 1998 (Table 1 and Annex 1).
10
Leading and responding
According to Article 9 of WHOs Constitution, the work of the Organization shall be carried out by the World Health
Assembly, the Executive Board and the Secretariat.
11
The World Health Report 1998
account: the health level of the coun- gional offices, and it was also opposed
tries to be included; the possible ex- to the decentralization of certain
istence in those countries of a perma- functions which in its opinion could
nent epidemic focus; the extent to only be efficiently discharged cen-
which those countries had managed trally. In 1953, the Executive Board
to overcome the health consequences carried out a full-scale organizational
of war; the efficiency of their health study of the regional structure. Its
administration; and their capacity to report gave a complete functional
resolve their problems. description for a composite or model
Finally the six WHO regions (Af- regional office. One of the main pur-
rica, the Americas, Eastern Mediter- poses of regional offices was to pro-
ranean, Europe, South-East Asia, vide effective contact between WHO
Western Pacific) were established. and national governments. To meet
The Assemblys decision concerning their many requests for advice, re-
Europe was limited to the setting-up gional advisers were attached to re-
One of the main of a temporary office to deal with the gional offices.
health rehabilitation of war-devas- The working methods of WHO
tated countries. In the Eastern Medi- which were established in the early
purposes of regional terranean area, it was decided to in- years are generally still in use today.
tegrate with WHO the existing Mari- To meet a request from a country, the
time and Quarantine Sanitary Coun- regional director would consult with
offices was to provide cil of Egypt located in Alexandria. An the national authorities to determine
agreement was concluded with the the form of international assistance to
effective contact Pan American Sanitary Organization: be supplied. On the basis of the re-
the Pan American Sanitary Bureau in quests received, the regional pro-
Washington, DC, was to assume, in gramme was planned, examining the
between WHO and addition to its former functions, the various projects with regard to their
new role of WHO Regional Office for conformity with policy guidelines and
the Americas. For further details, see their suitability for inclusion in a co-
national governments. Chapter 6. ordinated plan of development for the
Between 1949 and 1952, a certain region and country in question. For
number of transfers took place be- specific projects, the Organization
tween the regions. In 1953, the World would recruit and brief a suitable ex-
Health Assembly reaffirmed the prin- pert or team. The regional office en-
ciples that had prompted regional- sured liaison and cooperation with the
ization, found that they had been jus- national counterparts and local serv-
tified in practice, requested the Ex- ices. International staff were assigned
ecutive Board periodically to review to assist the government, not to con-
and report on regionalization, and trol the project, the course of which
requested the Director-General to was determined by the local needs,
provide the regional offices with guid- environment and epidemiological
ance and assistance, to ensure that conditions. Once the international
they conformed with the principles staff were withdrawn, the local serv-
and policies established by the gov- ices applied, extended and continued
erning bodies. The World Health As- the work, which became an integral
sembly recommended the inter- part of the national health services.
change of staff among regions and Technical and scientific meetings
between headquarters and regions. were used to give authoritative tech-
The Executive Board felt that there nical direction to the policies and pro-
should be no rigid allocation of func- grammes of WHO, to pool and ex-
tions between the central and re- change information, to suggest
12
Leading and responding
1946 Canada, China, Iran (Islamic Republic of), New Zealand, 1966 Guyana, Singapore
Syrian Arab Republic, United Kingdom of Great Britain
1967 Barbados, Lesotho
and Northern Ireland
1968 Mauritius
1947 Albania, Austria, Egypt, Ethiopia, Finland, Haiti, Iraq,
Ireland, Italy, Jordan, Liberia, Netherlands, Norway, 1971 Bahrein, Gambia, Oman
Saudi Arabia, South Africa, Sweden, Switzerland, Thai-
1972 Bangladesh, Fiji, Qatar, United Arab Emirates
land, Yugoslavia
1973 Democratic Peoples Republic of Korea, Swaziland
1948 Afghanistan, Argentina, Australia, Belarus, Belgium,
Brazil, Bulgaria, Chile, Denmark, Dominican Republic, 1974 Bahamas, Grenada, Guinea-Bissau
El Salvador, France, Greece, Hungary, Iceland, India,
1975 Botswana, Comoros, Mozambique, Tonga
Mexico, Monaco, Myanmar, Pakistan, Philippines, Po-
land, Portugal, Romania, Russian Federation, Sri Lanka, 1976 Angola, Cape Verde, Papua New Guinea, Sao Tome and
Turkey, Ukraine, United States of America, Venezuela Principe, Suriname
1949 Bolivia, Costa Rica, Ecuador, Guatemala, Honduras, Is- 1978 Djibouti
rael, Lebanon, Luxembourg, Paraguay, Peru, Republic
1979 Seychelles
of Korea, Uruguay
1980 Equatorial Guinea, Saint Lucia, San Marino, Zimbabwe
1950 Cambodia, Cuba, Indonesia, Lao Peoples Democratic
Republic, Nicaragua, Viet Nam 1981 Dominica
1951 Germany, Japan, Panama, Spain 1982 Bhutan
1952 Libyan Arab Jamahiriya 1983 Saint Vincent and the Grenadines, Solomon Islands,
Vanuatu
1953 Nepal, Yemen
1984 Antigua and Barbuda, Cook Islands, Kiribati, Saint Kitts
1956 Morocco, Sudan, Tunisia
and Nevis
1957 Ghana
1985 Brunei Darussalam
1958 Malaysia
1990 Belize, Namibia
1959 Colombia, Guinea
1991 Latvia, Lithuania, Marshall Islands, Micronesia (Feder-
1960 Benin, Burkina Faso, Cameroon, Central African ated States of), Tokelaub
Republic, Congo, Cte dIvoire, Gabon, Kuwait, Mali,
1992 Armenia, Azerbaijan, Bosnia and Herzegovina, Croatia,
Niger, Nigeria, Senegal, Togo
Georgia, Kazakstan, Kyrgyzstan, Puerto Rico,b Repub-
1961 Chad, Cyprus, Democratic Republic of the Congo, Mada- lic of Moldova, Slovenia, Tajikistan, Turkmenistan,
gascar, Mauritania, Sierra Leone, Somalia Uzbekistan
1962 Algeria, Burundi, Mongolia, Rwanda, Samoa, United 1993 Czech Republic, Eritrea, Estonia, Slovakia, The Former
Republic of Tanzania Yugoslav Republic of Macedonia, Tuvalu
1963 Jamaica, Trinidad and Tobago, Uganda 1994 Nauru, Niue
1964 Kenya 1995 Palau
1965 Malawi, Maldives, Malta, Zambia 1997 Andorra
a
Listed according to the year on which they became a party to the Constitution or the year of admission to associate membership.
b
Associate Member.
13
The World Health Report 1998
14
Leading and responding
15
The World Health Report 1998
same time people should have the that the community and the country
right as well as the duty, individually could afford. This technology had to
and collectively, to participate in the be applied through well-defined pro-
development of their own health. grammes delivered through a
Governments and the health profes- countrywide system incorporating the
sions also have the duty of providing above concepts and based on primary
the public with the information and health care.
social framework that will enable
them to assume greater responsibil- From Alma-Ata to 1998
ity for their own health. These prin-
ciples led to the further principle of A landmark in the development of
individual, community and national health policy was the International
self-determination and self-reliance Conference on Primary Health Care
in health matters, self-reliance not which took place in 1978 in Alma-Ata,
being synonymous with self-suffi- attended by delegations from 134
A landmark in the ciency. governments and by representatives
The distribution of resources af- of UN system organizations, other
fecting health came under close scru- agencies and NGOs.
development of health tiny. This led to the widespread ac- The Conference declared that the
ceptance of the need for a more eq- health status of hundreds of millions
uitable distribution of health re- of people in the world was unaccept-
policy was the sources within and among countries. able and called for a new approach to
Increasing emphasis was laid on pre- health and health care to shrink the
gap between the haves and have-
International ventive measures well integrated with
nots, to achieve a more equitable
curative, rehabilitative and environ-
mental measures. Biomedical and distribution of health resources, and
Conference on Primary health services research underwent to attain a level of health for all the
critical analysis, and policies were citizens of the world that would per-
aimed at orienting such research mit them to lead a socially and eco-
Health Care which more closely to the solution of prob- nomically productive life. The Con-
lems that are highly relevant to peo- ference further affirmed that the pri-
ples priority needs (socially relevant mary health care approach was essen-
took place in 1978 research). Within WHO, two special tial to an acceptable level of health
programmes were set up in response throughout the world and acknowl-
to this trend: in 1972, the Special Pro- edged that this could be attained
in Alma-Ata. gramme of Research, Development through a fuller and better use of the
and Research Training in Human worlds resources.
Reproduction; and in 1975 the Spe- Thus, in endorsing the report of
cial Programme for Research and the International Conference on Pri-
Training in Tropical Diseases. Health mary Health Care in 1979, the World
technology underwent the same kind Health Assembly and the United
of critical analysis, and the concept Nations General Assembly reaffirmed
of appropriate technology for health that health was a powerful lever for
emerged. This was understood to socioeconomic development and
mean a technology that is scientifi- peace, and that the goal of health for
cally sound, adapted to local needs, all by the year 2000, which was es-
acceptable to the community, main- sential for raising the quality of life,
tained as far as possible by the peo- could be attained through the primary
ple themselves in keeping with the health care approach. In 1981, the
principle of self-reliance, and capa- World Health Assembly adopted the
ble of being applied with resources Global Strategy for Health for All by
16
Leading and responding
17
The World Health Report 1998
The period 1985-1990 was char- At the same time, the developing
acterized by dramatic changes in both countries were experiencing an epi-
the political and the economic situa- demiological transition, with rapid
tions. On the positive side, there was ageing of the population together
a widespread move towards democ- with an increasing incidence of
ratization of political systems and noncommunicable diseases linked to
greater participation of people in de- changes in lifestyle. The growing
termining their own future. Human prevalence of cancer, cardiovascular
rights, equity and social justice in- disease, diabetes and other chronic
creasingly became basic concerns in conditions in addition to the long-
the political decision-making process. standing problems of communicable
The expression of individual and eth- diseases such as cholera, malaria and
nic rights, however, led to increased tuberculosis imposed a double bur-
violence and local conflicts and strife den on health care systems in these
in some countries such as Afghani- countries. There were also worrying
The developing stan. Economic policy also changed trends in mortality from accidents and
drastically and there was an increas- suicide in young adults, particularly
ing trend towards recognizing the in the developed countries. In addi-
countries were importance of health as a basic ele- tion, the pandemic of HIV infection
ment of development. However, the and AIDS imposed a particularly
experiencing an least developed countries faced diffi- heavy new burden on developing
culties even in maintaining basic countries. All these realities had to be
minimum services in the social sec- taken into account in implementing
epidemiological tor, including health. Structural ad- public health action geared to achiev-
justment programmes reduced pub- ing the goal of health for all through
lic expenditure and accelerated the primary health care.
transition, with rapid expansion of the private sector (the The election of Dr Hiroshi
drug market, private clinics, etc.). Nakajima as Director-General of
And yet, the period witnessed per- WHO in 1988 came at a time of glo-
ageing of the popula- ceptible improvements in health care bal political and economic upheaval
coverage and health status, though unprecedented since the end of the
such progress was uneven, differing in Second World War. Local civil strife
tion together with an various parts of the world, among and armed conflict became more
population groups within countries widespread, drawing WHO increas-
and in different age groups. While ingly into participation in humanitar-
increasing incidence commitment to the aims of health for ian emergency activities, and involve-
all remained firm and Member States ment in issues of human rights
generally adopted the primary health (Box 4). The end of the Cold War
of noncommunicable care approach as described in the Dec- stimulated a major realignment of
laration of Alma-Ata for the develop- global political and economic rela-
diseases linked to ment of their health care systems, the tionships. In many countries, these
implementation of strategies to global changes were accompanied by
achieve those aims had in many cases greater emphasis on market-based
changes in lifestyle. slowed down. This slowing down re- economies and democratic reforms
sulted not only from economic factors which stressed individual rights and
but also from the rigidity of health sys- responsibilities for health, food, hous-
tems, weak infrastructure, the con- ing, education and political represen-
straints on achieving real participation tation. At the same time, the decline
by all related sectors and the inad- in the pace of economic growth, the
equacy of efforts to promote health growing debt burden in many coun-
and prevent specific health problems. tries and economic structural adjust-
18
Leading and responding
19
The World Health Report 1998
20
Leading and responding
21
The World Health Report 1998
22
Leading and responding
tional health authorities and the trav- result of the rapid industrial expan-
elling public. The IHR cannot refer sion and development of a large
specifically to diseases that were not number of synthetic drug substances
known at the time the Regulations which became available internation-
were last revised. This is the case with ally, the World Health Assembly in
AIDS. Nevertheless, any require- 1950 recognized the need to develop
ments for an HIV antibody test cer- one standard name worldwide to
tificate (AIDS-free certificate) is identify newly developed pharmaceu-
contrary to the Regulations, since tical substances. A single internation-
Article 81 states that no health docu- ally recognized name for an active
ment, other than those provided for drug substance is vital for safe pre-
in these Regulations, shall be re- scribing and dispensing, and for ease
quired in international traffic. of communication among scientists
The success of WHO in globaliz- and health professionals. In contrast
ing disease control programmes to the tradenames, INNs are in-
might suggest that the defects of in- tended to be used as public property A single internationally
ternational law have not hobbled its without constraint, i.e. nobody should
effectiveness in improving health care own any proprietary rights, thus the
worldwide. However, despite having inclusion of nonproprietary in the recognized name
the authority to do so, WHO has been designation INN. WHO collaborates
reluctant to use international law, and closely with national nomenclature
its effectiveness has been questioned. commissions to select a single name
for an active drug
A 1975 WHO publication stated that with worldwide acceptability for each
the IHR have not functioned satisfac- active substance that is to be mar- substance is vital
torily at times of serious disease out- keted as a pharmaceutical. To date
breaks. More recently, WHOs efforts some 6900 names have been selected.
with the IHR have been called a fail- The selection of an INN follows es- for safe prescribing
ure, and noncompliance with these tablished rules so that the name itself
regulations has increased in connec- communicates to medical and phar-
tion with reporting disease outbreaks. maceutical health professionals the and dispensing.
WHOs reluctance to apply inter- therapeutic or pharmacological group
national law has been attributed to its to which the active drug substance
organizational culture, which is domi- belongs. Newly selected INNs are
nated by scientists, doctors and medi- published first as proposed and, pro-
cal experts. The global threat posed vided no objection was raised within
by these infections represents in a permissible period of four months,
many ways a test case for international again as a recommended INN in
public health law. The effectiveness WHO drug information. The list gives
of international law depends on the the names in Latin, English, French
consent of States, which means that and Spanish. The cumulative list
sovereignty and its exercise deter- which is published periodically in-
mine the fate of international legal cludes in addition the Russian version
rules. In adopting a legal strategy for and more detailed information, such
its emerging infectious disease action as references to pharmacopoeial
plan, WHO has to convince its Mem- monographs and international and
ber States to take certain actions in national names that are identical or
response to disease emergence. different to INNs. A CD-ROM ver-
International Nonproprietary sion is in preparation.
Names for pharmaceutical sub- The International standards for
stances (INNs) are also referred to drinking-water quality were first pub-
as common or generic names. As a lished by WHO in 1958 as an aid to
23
The World Health Report 1998
24
Leading and responding
Trade in services is a rapidly growing activity accounting care (i.e. equal utilization of health services for the same
for an increasing share of national product in both devel- need, with users contributing according to their economic
oping and industrialized countries. The World Trade Or- capacity); quality of care (this refers to the standard of
ganization (WTO) has organized multilateral negotiations the health care system); and efficient use of resources
to liberalize trade in services, resulting in the General (i.e. a given output is produced at minimum cost, or maxi-
Agreement on Trade in Services (GATS). mum output is produced at a given cost).
Services are generally described as being distinct However, some health professionals tend to think of
from physical commodities, being intangible, nontrans- international trade as an area of little relevance for public
ferable economic goods. For trade purposes, GATS de- health activity. Yet even as early as 1949 the World Health
fines services in terms of the ways in which they can be Assembly called the attention of the Director-General to
supplied; e.g. across a border (in the health field, an ex- the need for eliminating quarantine restrictions of doubt-
ample would be telemedicine), or through people who are ful medical value which interfere with international trade
service suppliers (such as health professionals working and travel. But not until 1995 did an international trade
outside their home country). agreement come into force to respond to the concern
Relatively few countries have made commitments in that as other trade barriers came down, sanitary and
the health sector under GATS. Some 27% of WTO Mem- phytosanitary measures might be used for protectionist
bers (half industrial and half developing countries) agreed purposes. It therefore encourages countries to apply har-
to open up hospital services to foreign enterprises, and monized measures based on international standards,
35% (in similar proportions) did so for medical and den- guidelines and recommendations which, in turn, reinforces
tal services. Some 19% (mostly industrial countries) WHOs norms. For example, the agreement stipulates
scheduled the services of health personnel other than phy- that in the case of food safety the international refer-
sicians. ences are those of the Codex Alimentarius Commission
It is much too early to assess the impact of the Agree- which implements the Joint FAO/WHO Food Standards
ment on trade in health services. However, there is a grow- Programme.
ing awareness of its potential for both industrial and de- Nor is WHO called upon solely for its norms. Its exper-
veloping countries. In the general context of rising health tise is becoming increasingly valuable in a particularly sen-
care costs coupled with a growing trend to reduce public sitive area of trade relations, that of settling disputes. In a
spending in the social sectors, the advantages of export- dispute between the European Union and the United States
ing health sector skills and technology, or of attracting in 1997, WHO experts provided scientific evidence on risk
higher-spending foreign customers to health facilities, are assessment procedures used to determine potential risk
obvious. to human health, a key element for the findings of WTOs
But how can objectives of profitability and resource dispute settlement panel. As expanding trade raises the
generation be reconciled with that of improving the popu- likelihood of litigation, WHO may well in the future be in-
lations health status? WHO has identified three interim creasingly called upon to advise as the only international
policy objectives to further that goal: equitable access to source of impartial scientific expertise in health matters.
25
The World Health Report 1998
26
Leading and responding
the country was stressed from the of their needs in support of their strat-
outset, and repeated in every succes- egies. WHO introduced a planning
sive general programme of work. process in the field of health during
When WHOs involvement is fin- the late 1950s, based on modern sci-
ished, the country should be able to ence and technology. This was em-
continue on its own. phasized particularly in the Fifth gen-
By 1960, the distinction between eral programme of work, which iden-
the two major functions had become tified four principal programme ob-
artificial. By 1975, a study on the in- jectives: the strengthening of health
terrelationships between the central services; the development of health
technical services of WHO and pro- manpower; disease prevention and
grammes of direct assistance to Mem- control; and the promotion of envi-
ber States led to the recognition that ronmental health. The Sixth summa-
an integrated approach to the devel- rized the criteria for WHOs involve-
opment of programmes was needed, ment as: the problem has been clearly
all programme activities at all levels defined; the problem is of major pub- In the 1970s and
being mutually supportive and parts lic health and socioeconomic impor-
of a whole, with more responsibility tance; the potential for the solution
being given to WHOs country offices. of the problem has been demon- 1980s, WHO
This led to a significant evolution in strated; there is a strong rationale for
the concept of WHOs technical co- WHOs involvement; and WHOs
operation. Formerly, WHO activities non-involvement would cause serious
increasingly promoted
in countries tended to be based on adverse health repercussions.
the traditional concept of technical The programme also emphasized technical cooperation
aid or assistance, implying a donor- the need to have specified targets, and
to-recipient relationship without mu- sometimes output indicators, for each
tual exchange. This was replaced by programme objective and stipulated among developing
a new concept of technical coopera- that the progress of the work towards
tion characterized by equal partner- those targets was to be assessed by the
ship among the cooperating parties. regional committees, the Executive countries.
Towards the end of the 1970s, there Board and the World Health Assembly.
was a shift in the WHO regular The Seventh and Eighth general
budget towards technical coopera- programmes of work were somewhat
tion: the proportion allocated in- more elaborate, indicating the main
creased from 51% in 1977 to 60% in thrust of each programme. Following
1980. In the 1970s and 1980s, WHO the Alma-Ata Conference and the
increasingly promoted technical co- subsequent launching of the global
operation among developing coun- health-for-all strategy, the WHO Sec-
tries. In the 1990s the Organization retariat produced a medium-term
made efforts to ensure that its re- programme for each programme in
gional and global levels acted in com- respect of the periods covered by the
plete coordination. Sixth, Seventh and Eighth general
programmes of work, so as to facili-
Criteria for activities tate the preparation of the pro-
and priorities gramme budgets to reflect directly
the objectives and targets that were
Within this framework, WHOs activi- set. The annual programme and
ties were aimed at yielding results that budget estimates became the biennial
could be demonstrable to govern- programme budget as from 1976-
ments. The activities therefore fol- 1977 to allow for flexibility in imple-
lowed a careful analysis with countries mentation. To eliminate certain weak-
27
The World Health Report 1998
nesses that had been observed (focus general programmes of work empha-
on resources allocated and activities sized protecting mother and child
planned, rather than on products or health, including family planning, and
outputs; lack of flexibility to cope with health of workers and elderly people.
changing situations and actual per- The Seventh stressed action against
formance; and fragmentation of pro- undernutrition and nutritional defi-
grammes instead of their integration), ciencies, but also against nutritional
the Ninth general programme of excess and imbalance.
work simplified its contents, reduced The Fifth noted that a dark side
the number of programmes and set of industrialization and urbanization
25 numerical targets to be attained by was the emergence of factors detri-
countries by 2001. mental to health, e.g. pollution, road
accidents and stressful city life, and
Programme orientation that the previous concept of environ-
and targets mental sanitation had evolved into
The scope of general that of environmental health.
Strengthening national health The Eighth general programme of
services. The First general pro- work noted steady progress in the ef-
health protection and gramme of work stressed the need to forts to address environmental and
integrate specialized health service social issues affecting health, and pro-
activities in a general health pro- moting and protecting the health of
promotion extends gramme (or basic health services). specific population groups such as the
The Fifth general programme of work elderly. It also stressed that the scope
beyond prevention emphasized the need for maximum of general health protection and pro-
coverage of health programmes, par- motion extends beyond prevention
ticularly of the potentially underprivi- and control of diseases by medical
and control of leged, as was the need for pro- technology; it is an evolving concept
grammes planned in advance, instead that encompasses fostering lifestyles
of assistance to single services of lim- and other social, economic, environ-
diseases by medical ited scope. This led to the adoption mental and personal factors condu-
in 1975 of the new approach of pri- cive to health.
mary health care for the promotion The Ninth general programme of
technology. of national health services. To coun- work envisages that WHO continues
ter the perception that the develop- its support to the implementation of
ment and strengthening of the health strategies agreed upon at the United
system infrastructure is a tedious and Nations Conference on Environment
bureaucratic job, in comparison with and Development in 1992 to achieve
specific activities which appear more ecologically-sustainable development
glamorous and more important the and to prevent and control environ-
Eighth general programme of work mental health risks.
emphasized the strengthening of Preventing and controlling spe-
health infrastructure. Education and cific health problems. The diseases
training of the various categories of of great public health concern in the
health personnel was given high pri- early days of WHO included those
ority from the beginning, both from affecting maternal and child health,
the quantitative and qualitative points malnutrition, tuberculosis, malaria,
of view, to cope with the changing venereal diseases, endemic trepone-
needs of the community and with the matosis, smallpox, plague, cholera
evolving health technologies. and yellow fever. The Organization
Promoting and protecting has adapted itself continually to the
health. The Fifth, Sixth and Seventh changing world situation. Starting
28
Leading and responding
29
The World Health Report 1998
30
Leading and responding
31
The World Health Report 1998
32
Leading and responding
33
The World Health Report 1998
The exciting and rapid develop- tributed free of charge. In its early
ments in communication and the dis- years, the library supplied thousands
semination of information that have of books, journals, photostats and mi-
taken place during that half-century crofilms to Member governments to
have had a profound impact on how replace collections damaged during
WHO does its work. In 1977 the first the Second World War and to furnish
personal computers went on sale to core sets of medical literature to
the general public, and are now com- countries. In the early 1970s, the
monplace in many parts of the world. WHO Medline Centre operated from
They enable the daily use by millions the library, providing searches from
of people worldwide of the Internet Medline, and photocopies of articles
(originally a network of computers in to people working in developing
government, academic and scientific countries. In 1986 the library moved
institutions developed in the 1960s in from a manual to an automated li-
the United States to enable research- brary information system and all li-
Internet surfers ers to share information). The brary functions were automated si-
number of Internet users is predicted multaneously. From the mid-1980s
to reach 700 million by the year 2000. onwards the library moved ahead with
can find out about By connecting to WHOs site on the its electronic library initiative. Library
World Wide Web, Internet surfers services were offered 24 hours a day,
can find out about the work of WHOs CD-ROM databases were intro-
the work of WHOs programmes relating to all aspects of duced, and an optical disk system re-
health and disease, and have access placed paper for full-text storage of
programmes relating to the database of WHOs library. WHO technical documents.
Abstracts from WHOs journals are The WHO library acts as a cen-
available, as is the complete text of tral purchasing agent to obtain books,
to all aspects of many WHO newsletters and docu- journals and information material for
ments. The Internet user can choose libraries worldwide, enabling librar-
from the hundreds of books in WHOs ies with a lack of foreign currency to
health and disease, publications catalogue and send in an order material under the WHO re-
order, or can consult any of the reso- volving fund. It also runs an interna-
lutions and decisions of the WHO tional exchange of free books and
and have access governing bodies dating back to 1948. journals in 72 countries (comprising
WHO has also produced several CD- 219 libraries). Document delivery is
ROMs that contain either encyclo- provided under an agreement with
to the database of paedic collections of data or compi- the National Library of Medicine in
lations of journal issues. Washington and the Library of the
Communication is not merely a British Medical Association.
WHOs library. one-way process. WHOs computers In 1997, WHOs reference librar-
are host to over 60 e-mail discussion ians answered an estimated 17 000
groups on a whole range of health queries from around the globe deal-
concerns and aspects of the Organi- ing with the work of WHO that came
zations work. These e-mail lists exist in by letter, fax, e-mail, telephone and
so that information can be shared and in person. The indexing and catalogu-
ideas exchanged openly in an infor- ing of recently-acquired non-WHO
mal manner. publications are being outsourced to
A strong working library was rec- a commercial firm, and procedures
ognized as essential to the technical for online input of these data to the
work of WHO as early as 1946. By library database have been estab-
1947 the library collection was begun lished.
and a monthly Library news was dis-
34
Leading and responding
35
The World Health Report 1998
Recognizing that the extension to all peoples of the ben- equity of access to health information have been consist-
efits of medical, psychological and related knowledge is ently affirmed, the means of communication of WHOs lan-
essential to the fullest attainment of health, WHO seeks guage services have kept pace with the development of
to communicate the best available health information to information and communication technologies. Thus, WHOs
all Member States in the most effective way. To ensure wealth of expertise in technical terminology, built up over
equity of access to health information in a polyglot, 50 years, is no longer archived on index cards and dis-
multicultural world, WHO must communicate essential seminated in printed bulletins, but is maintained and dis-
health information in different languages. seminated in the form of a computerized terminology da-
WHOs translators a judicious mix of fixed-term, tem- tabase.
porary and free-lance staff work on a wide range of ma- A just-completed study of the translation process as
terial, especially scientific and technical information, and part of WHOs documentation chain has yielded recom-
policy documents for the deliberations of the governing mendations that, when implemented, will result in effi-
bodies. ciency savings. The integrated management of the multi-
The rules of procedure of the World Health Assembly lingual flow is to be achieved through a computerized job
and Executive Board provide that Arabic, Chinese, Eng- tracking system, while an electronic document process-
lish, French, Russian and Spanish shall be the official lan- ing system will make possible for the first time an elec-
guages. Regional committees have their own distinctive tronic repository for all WHO documents and publications
pattern of languages. In 1948, the Executive Board de- in all languages.
cided that publications should appear in English and French. At the same time, technology is of little help without
Spanish was added in 1954. Russian became a language the human values of scientific training, linguistic talent,
of publication in 1960. Arabic and Chinese were included and respect for the author and the reader, as appears
shortly before the Alma-Ata Conference in 1978. daily in the work of WHOs language services. Since any
Recognizing that equity of access to health informa- information pertaining to human health must meet the
tion cannot be ensured by six official languages that are highest standards, WHO translators must also render
unknown to many millions of intended readers, a WHO has ideas from one language into another with understanding
sought to encourage translations into national and regional and accuracy of meaning, context and style. At WHO,
languages outside the Organization, in collaboration with translation talent serves health workers in countries
country and regional offices. By 1997, translations of WHO throughout the world.
technical books and documents in over 60 target languages
had been published with some 100 translated WHO books
published annually by publishers and scientific institutions, a
For example, it is likely that many of the 476 million speakers of Hindi,
ministries and professional associations in countries, at 207 million speakers of Bengali, 187 million speakers of Portuguese, 126
million speakers each of Japanese and German, 170 million speakers of
no additional cost to WHO. Malay and Indonesian particularly primary or intermediate-level health
While the principles of parity of official languages and workers are unable to read or work in one of WHOs official languages.
36
Leading and responding
37
The World Health Report 1998
38
Measuring health
Chapter 2
Measuring health
I
n view of major limitations im- conventional indicators such as life
posed by the lack of suitable expectancy, mortality and morbidity.
measurements that can capture Efforts are under way, however, to
the meaning of health as dened in develop indicators of positive health
the WHO Constitution (Health is such as health expectancy and its vari-
a state of complete physical, mental ants, but problems of standardization
and social well-being and not merely of denitions and comparability of
the absence of disease or inrmity) values derived inhibit their usage for
this assessment of health trends uses trend assessment at this stage.
The Global Strategy for Health for
Fig. 1. Progress
Progressin in achievingglobal
achieving globaltargets
targetsfor
forhealth
healthfor
forall
all All by the Year 2000 (HFA2000) set
a
by the year
by the year 20002000
a the following guiding targets:
A. Life expectancy at birth -- target: above 60 years life expectancy at birth above 60
a
Percentages of the total population of all Member States.
be no country with a life expectancy
39
The World Health Report 1998
Fig. 2. Survival curves, 1955 - 2025
Fig. 2. Survival curves, 1955-2025
World Least developed countries
100 H
F
J
B 100 F
H
J
B
F
97
F F F
95 F F
H
93 H F F F F94
F F F
90 J H H
90 H H F F 90 91 F
F F
89 J
J J H H F H87 F F
B
82 84 J J H H J82 H H 79
80 J J H F
81 80 H F
B B J J B76 J H H F
B
74 H F J J72 H F
70 B B J H
70 70 H
B B J B B J J F
69
F J H
B H
% of survivors
% of survivors
61 H
J B62 J F
60 B 60 B J H
B B
J H F B J H
50 B 50 B J F
45
B J
B
B J H
47
40 H 40 B 39 H
J
B F
B
30 J F 30 J H
B B
28
20 20 B J H
B H F
J B J
10 B 10 B H
LYT 98023
J
0 0
B
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+
Age Age
B 1955 at birth below 50. Even for the least been increasing signicantly since
J 1975 developed countries (LDCs), the 1955. As shown in Fig. 2, the overall
H 1995 increase was about 15 years (from 37 trend is that global survival rates the
2025
in 1955 to 52 in 1995). The increase is chances of surviving 5, 20, 65 or 80
F
expected to be 13 years between 1995 years have improved during the
and 2025, when life expectancy for period 1955-1995. The same is true
these countries will reach 65. In all, of the equivalent survival rates in
more than 5 billion people now live in the LDCs, but the percentages are
120 countries where life expectancy considerably lower than the global
at birth is above 60. About 890 mil- percentages. For every 100 babies
lion people live in 26 countries where born in 1995, globally 70 are expected
life expectancy at birth increased to live to at least 65 years, but in the
by 10 years or more between 1975 LDCs only 47 are expected to do so.
and 1995. About 1 billion people Globally for every 100 persons aged
live in 56 countries where a similar 20 in 1995, about 70 are forecast to
increase is expected between 1995 survive at least 50 years (to age 70).
and 2025. Such spectacular progress Only 50 are likely to survive to this
is not shared by all, however. More age in the LDCs.
than 50 million people are still living
in countries with a life expectancy at
birth below 45. About 300 million Mortality trends
people live in 16 countries which
experienced a decrease in life ex- In its search for a simple and mean-
pectancy at birth between 1975 and ingful measure of health, WHO
1995. The range in national values for proposed in its second Report on the
life expectancy at birth is expected World Health Situation (in 1963), the
to decrease from 43 years in 1955 to proportional mortality ratio the
31 in 2025. number of deaths at age 50 and above
Some of the population who are as a percentage of deaths at all ages
likely to be alive by the end of the as a possible indicator. Applying this
21st century are already born and measure to study historical trends,
alive today. Their survival rates have globally the proportional mortality
40
Measuring health
LYT 98017
<5 20-64
fell by more than 40% from 1955 to 5-19 65+
1995 and should be about 950 deaths
World
per 100 000 in 2025. There was also 1955 1975 1995 2025
a reduction globally of 67% from 3%
8%
1955 to 1995 in death rates among 22% 21%
children under 5 and of 66% among 40% 32% 32%
43% 7% 27%
those aged 5-19. Among those aged 62%
28%
27% 9% 29%
20-64, the reduction was about 50%. 10%
In respect of those aged 20-64, death
rates declined by 56% for females but Total: 51.2 Total: 46.1 Total: 51.7 Total: 65.8
only 49% for males. Here too, while
Least developed countries
age- and sex-specic mortality has
1955 1975 1995 2025
been falling, the pace of decline is
not uniform. 11% 12% 16% 23%
31%
Fig. 3 shows the number of deaths
26% 48% 25% 48% 40%
at different ages and their distribu- 29% 10%
41
The World Health Report 1998
50% in 1955, had decreased to 41% estimated at 430 maternal deaths per
by 1995, and is expected to be 23% 100 000 live births in 1990 globally,
in 2025 about half of what it was in but it varies widely among and within
1955. Unfortunately, the proportion countries. For every 100 000 live
of deaths among adults the working- births there were about 13 mater-
age population has been increasing nal deaths in the developed market
from about 25% in 1975 to 29% in economies, but more than 1050 in the
1995, and is expected to be almost LDCs. In other words, one woman
36% in 2025. dies of pregnancy-related causes for
Worldwide, there have also been every 100 babies born alive. Less
differential patterns in age- and sex- is known about the incidence and
specic death rates since 1955. The prevalence of pregnancy-related mor-
death rate per 100 000 population bidity and disabilities. Although the
declined between 1955 and 1995 immediate causes of maternal mortal-
At least in respect from 5280 to 1720 among children ity and morbidity are inadequate care
under 5; from 620 to 210 among older of the mother during pregnancy and
children and adolescents aged 5-19; delivery, other factors include wom-
of mortality, from 1040 to 500 among adults aged ens subordinate status, poor health
20-64; and from 7550 to 6040 among and inadequate nutrition.
older people aged 65 and above. Under-5 mortality rates de-
gender difference The relative death rate among creased from 210 per 1000 live births
females compared with males (the in 1955 to 121 in 1975, and to 78 per
ratio of age-specic death rates for 1000 in 1995 a decrease of 42%
seems to favour females to that of males) increased between 1955 and 1975 and of 36%
from 96% in 1955 to 99% in 1995 for between 1975 and 1995, when the
the female population children under 5, but decreased from child survival initiative was launched.
102% to 97% for older children and It is expected to decline further to 37
adolescents aged 5-19, from 79% to per 1000 live births by 2025.
at all ages. 68% for adults aged 20-64 and from In 1995, at least 105 countries
85% to 81% for older people aged 65 (with 50% of global live births and
and above. Even for the age group 50% of children under 5 worldwide)
15-49, the ratio of death rates among have an estimated under-5 mortality
women of childbearing age to men below 70 per 1000 live births. In 1955,
aged 15-49 declined from 84% to this was the case for 40 countries
73%. At least in respect of mortality, (18% of global live births) and in
gender difference seems to favour 1975 for 75 countries (37% of global
the female population at all ages, live births). The pace of progress in
although the relative decline in rates under-5 mortality reduction during
among children under 5 has not been 1975-1995 was not so fast as during
so rapid as for other age groups. 1955-1975. It is expected to acceler-
The death rate among women ate during 1995-2025 with 151 coun-
of childbearing age decreased from tries (89% of global live births) having
620 per 100 000 in 1955 to 230 per an under-5 mortality rate below 70
100 000 in 1995, and is likely to reach per 1000 by the year 2025. In 1955
140 per 100 000 by 2025. Globally, there were only three countries with
about 585 000 women die each year an under-5 mortality rate below 20
of pregnancy-related causes, most of per 1000 live births; by 2025 at least
which are preventable. The mater- 84 countries are expected to have
nal mortality ratio, representing such a low rate. While all countries
the risk of pregnancy-related deaths improved their under-5 mortality, at
associated with each pregnancy, was least 82 countries (with about two-
42
Measuring health
a b c
thirds of live births worldwide) regis- Fig.
Fig. 4.
4. Infant , neonatal
Infant, a
neonataland
b perinatal mortality,
and perinatalc mortality,
tered signicant decreases in under-5 byby
level
levelof of
development, 1983
development, andand
1983 1995
1995
mortality of at least 40 per 1000 live
births between 1975 and 1995. Developing world Developed world
100
Newborn mortality
In the developed market econo-
Fetal mortality
(Per 1000 births)
developing world, under-5 mortality 20
declined by 45% during 1955-1975
and by 37% during 1975-1995 and 40
1983 1995 1983 1995
LYT 98006
is expected to reach by 2025 a level Year
of 40 from the present level of 87 a Post-neonatal mortality
per 1000 live births. However, even Infant mortality = early, late and post-neonatal mortality. Late neonatal mortality
b
Early neonatal mortality
in countries that have made notable c Neonatal mortality = early and late neonatal mortality. Fetal mortality
Perinatal mortality = fetal and early neonatal mortality.
progress, child mortality is still unac-
ceptably high. The LDCs in particular
continue to struggle to reduce mortal- mies, the IMR declined by 58%
ity rates; under-5 mortality decreased between 1955 and 1975 and by a
from about 280 to about 150 per 1000 further 57% between 1975 and
live births between 1955 and 1995. 1995. The present level is of 6 per
Seven countries six of which are in 1000 live births and it is expected to
Africa still have under-5 mortality reach by the year 2025 a level of 5.
rates greater than 200 per 1000 live The developing world experienced
births in 1995. a decline in the IMR of 41% during
Infant mortality has continued to 1955-1975 and of 36% during 1975-
decline in recent decades. Globally, 1995, and it is expected to decline
the infant mortality rate (IMR) further to reach a level of 32 by the
fell from 148 per 1000 live births in year 2025 from the present level of
1955 to 90 per 1000 in 1975, and to 62 per 1000 live births. In the LDCs,
59 per 1000 in 1995 a decrease of the IMR changed only from 186
39% from 1955 to 1975, and a further to 104 per 1000 between 1955 and
34% decrease from 1975 to 1995. The 1995 about 75% of the decline
IMR is projected to reach a value of experienced by developing countries
29 per 1000 live births in 2025. other than LDCs. In 1995, there were
Overall, the number of countries 24 countries 20 of them in Africa
with an IMR below 50 per 1000 live where one in every 10 liveborns
births increased from 23 countries in died within a year of birth. By 2025
1955 to 70 in 1975, and to 102 (34% the IMR is expected to decline to 50
of global live births) in 1995. It is per 1000 still double the average of
expected that by 2025 there will be 25 per 1000 live births for developing
at least 151 countries (43% of global countries other than LDCs.
live births) with an IMR below 50 per While infant mortality declined
1000. In 1955, the ratio of the highest markedly during the early 1980s and
value of IMR to the lowest value was late 1990s, most of this improvement
13 to 1; in 1975 it was 25 to 1; and in was among older infants. The death
1995, the ratio was 42 to 1. toll during the perinatal period (still-
For the developed market econo- births and during the rst week of
43
The World Health Report 1998
Fig.
Fig. 5. Globalcauses
5. Global causesof
of death, 1997 aa
death, 1997 life) has fallen only slightly from 64
to 57 deaths per 1000 live births. It
Other and unknown causes
6 250 (12%)
is also estimated that mortality dur-
Diseases of the ing the neonatal period (the rst 28
respiratory system days of life) has declined from 40 to
2 890 (6%) 36 deaths per 1000 live births during
1983-1995 (Fig. 4). In all, there have
been about 4 million stillbirths, 3.2
Infectious and parasitic
diseases 17 310 (33%)
million deaths during the rst week
of life and 1.6 million deaths among
newborns living more than a week
Diseases of the circulatory but dying within 28 days after birth.
system 15 300 (29%) There are about 9 million deaths of
which 7.5 million are perinatal deaths
and 4.8 million neonatal deaths annu-
Cancers
6 235 (12%) ally worldwide.
Perinatal
and neonatal causes
3 630 (7%)
Disease trends
Maternal causes Based on available information,
585 (1%)
WHO estimates that, of more than
50 million deaths worldwide in 1997,
a Deaths in thousands and percentages of total. about one-third were due to infec-
Infectious and parasitic diseases include acute lower respiratory infections and neonatal tetanus and are tious and parasitic diseases such as
LYT 98025
excluded from diseases of the circulatory system and perinatal and neonatal causes respectively.
acute lower respiratory diseases,
tuberculosis, diarrhoea, HIV/AIDS
and malaria; 29% were due to circula-
Fig. 6. Causes of death: distribution of deaths by main causes, tory diseases such as coronary heart
Fig. 6. Causes of death: distribution of deaths by main causes, disease and cerebrovascular diseases;
by level of development, 1985, 1990 and 1997
by level of development, 1985, 1990 and 1997 and about 12% were due to cancers
1985 1990 1997 (Fig. 5). While deaths due to circula-
1% 4% 1% 1% 1% tory diseases declined from 51% to
5% 46% of total deaths in the developed
18% 23% 23% world during the period 1985-1997,
Developed world
44
Measuring health
Table 3. Global health situation: mortality, morbidity and disability, selected causes for which data
are available, all ages, 1997 estimates a
Number (000)
Deaths Cases Persons with severe
Diseases/conditions activity limitation b
New
All
45
The World Health Report 1998
Number (000)
Deaths Cases Persons with severe
Diseases/conditions activity limitation b
New
46
Measuring health
Number (000)
Deaths Cases Persons with severe
Diseases/conditions activity limitation b
New
a
No adjustments have been made for comorbidity. Caution should be exercised when using these data for comparative purposes as estimation procedures
may have been rened from one World Health Report to the next.
b
Permanent and long-term.
c
Incidence gure refers to episodes.
d
Number of infected persons is 1.25 billion.
e
In addition, approximately 50 million doses of vaccine are used for post-exposure prophylaxis.
f
Number of infected persons is 1.38 billion.
g
Number of infected persons is 1 billion.
h
Includes Non-Hodgkin lymphoma, multiple myeloma and Hodgkin disease.
i
This excludes 4.8 million malnutrition-associated deaths among children under 5.
j
Figure refers to children under 5.
k
This excludes neo- and perinatal deaths due to neonatal pneumonia, neonatal tetanus and neonatal diarrhoea.
... Data not available or not applicable.
47
Table 4. Global health situation: leading causes of mortality, morbidity and disability, selected causes for which data are available, all ages, 1997 estimatesa
48
Persons with severe Deaths
Deaths Cases activity limitation Leading selected causes of mortality Rank Number (000)
Ischaemic (coronary) heart disease 1 7 200
Rank Number Rank New Rank All Rank Number Cerebrovascular disease 2 4 600
Diseases/conditions (incidence) (prevalence) Acute lower respiratory infection 3 3 745
(based on ICD-10) Tuberculosis 4 2 910
COPD 5 2 890
(000)
Diarrhoea (including dysentery) 6 2 455
(000) (000) HIV/AIDS 7 2 300
(000) Malaria 8 1 500-2 700
The World Health Report 1998
Prematurity 9 1 120
Ischaemic (coronary) heart disease 1 7 200 ... ... ... Cancer of trachea, bronchus and lung 10 1 050
Cerebrovascular disease 2 4 600 ... 9 000 ... Measles 11 960
Acute lower respiratory infection 3 3 745 3 395 000 ... ... Birth asphyxia 12 920
Tuberculosis 4 2 910 7 250 16 300 8 420 Cases
COPD 5 2 890 ... 5 600 000 ... Leading selected Rank New Rank All
Diarrhoea (including dysentery) 6 2 455 1 4 000 000 ... ... causes of morbidity (incidence) (prevalence)
HIV/AIDS 7 2 300 5 800 30 600 ...
Malaria 8 1 500-2 700 2 300 000-500 000 ... ...
Prematurity 9 1 120 ... ... ... (000) (000)
Cancer of trachea, bronchus and lung 10 1 050 1 190 4 465 ... Diarrhoea (including dysentery) 1 4 000 000 ...
Measles 11 960 31 075 ... ... Malaria 2 300 000-500 000 ...
Birth asphyxia 12 920 ... ... ... Acute lower respiratory infection 3 395 000 ...
Occupational injuries 4 250 000 ...
Occupational injuries 330 4 250 000 ... 8 25 000 Occupational diseases 5 217 000 ...
Occupational diseases ... 5 217 000 ... 9 20 000 Trichomoniasis 6 170 000 113 000
Trichomoniasis ... 6 170 000 113 000 ... Mood (affective) disorders 7 122 865 8 340 000
Mood (affective) disorders ... 7 122 865 8 340 000 1 146 000 Chlamydial infections 8 89 000 85 000
Hepatitis B 9 67 730 ...
Chlamydial infections ... 8 89 000 85 000 ... Gonococcal infection 10 62 000 23 000
Hepatitis B 605 9 67 730 ... ... Amoebiasis 11 48 000 ...
Gonococcal infection (gonorrhoea) ... 10 62 000 23 000 ... Whooping cough (pertussis) 12 45 050 ...
Amoebiasis (Entamoeba histolytica) 70 11 48 000 ... ... Iron deciency anaemia ... 1 1 788 600
Neck and back disorders ... 2 1 039 200
Whooping cough (pertussis) 410 12 45 050 ... ... Goitre ... 3 844 700
Iron deciency anaemia ... ... 1 1 788 600 ... Hypertensive disease ... 4 690 600
Neck and back disorders ... ... 2 1 039 200 ... COPD ... 5 600 000
Goitre ... ... 3 844 700 ... Anxiety disorders ... 6 400 000
Arthritis and arthrosis ... 7 354 500
Hypertensive disease ... ... 4 690 600 ... Ascariasis (roundworm) ... 9 250 000
Anxiety disorders ... ... 6 400 000 ... Schistosomiasis ... 10 200 000
Arthritis and arthrosis ... ... 7 354 500 ... Persons with severe activity limitation (permanent and long-term)
Ascariasis (roundworm) 60 ... 9 250 000 ... Leading selected causes Rank Number
(000)
Schistosomiasis 20 ... 10 200 000 3 120 000
Hepatitis C ... ... 11 170 000 ... Mood (affective) disorders 1 146 000
Hearing loss (41 or more decibels) 2 123 000
Malnutrition including PEM 370 ... 11 170 000 ... Schistosomiasis 3 120 000
Hearing loss (41 or more decibels) ... ... 123 000 2 123 000 Lymphatic lariasis 4 119 100
Lymphatic lariasis ... ... 119 100 4 119 100 Cretinoids 5 49 600
Cretinoids ... ... 49 600 5 49 600 Mental retardation (all types) 6 36 000
Schizophrenic disorders 7 27 000
Mental retardation (all types) ... ... 60 000 6 36 000 Occupational injuries 8 25 000
Schizophrenic disorders ... 4 500 45 000 7 27 000 Occupational diseases 9 20 000
Cataract-related blindness ... ... 19 340 10 19 340 Cataract-related blindness 10 19 340
Cretinism ... ... 16 500 11 16 500 Cretinism 11 16 500
Dementia 12 15 950
Measuring health
49
The World Health Report 1998
Table 5. Importance of selected diseases and conditions over time according to the Report on the World
Health Situation
Disease Report 1 Report 2 Report 3 Report 4 Report 5 Report 6 Report 7 Report 8
1954-56 1957-60 1961-64 1965-68 1969-72 1973-77 1978-84 1985-89
Infectious diseases
Malaria
Tuberculosis
Cholera
Poliomyelitis
Yaws
Hepatitis, infectious
Relapsing fever
Plague
Yellow fever
Trachoma
Onchocerciasis
Leprosy
Smallpox
Schistosomiasis
Sexually transmitted diseases
Inuenza
Filariasis
Dysentery
Trypanosomiasis, African
Trypanosomiasis, American
Ascariasis
Ancylostomiasis
Trichuriasis
Diarrhoea
Meningitis
Acute respiratory disease
Diphtheria
Viral haemorrhagic fever
Endemic treponematoses
Measles
Tetanus
Dracunculiasis
AIDS
Pneumonia
Dengue haemorrhagic fever
Pertussis
Rabies
Japanese encephalitis
Leishmaniasis
Chronic conditions
Cancer
Circulatory diseases
Endocrine, nutritional and metabolic
diseases
Accidents
Mental disorders
Others
Handicap
Tobacco-related disorders
Alcohol-related disorders
Occupational injuries
Agrochemical-related hazards
50
Measuring health
10100
America. >100
There has been an important No data available
51
The World Health Report 1998
A WHO plan to treat more than 1 billion people a fth SmithKline Beecham plc, which has already supported
of the world population with a dose of medicine could the development of drugs and programmes for controlling
lead to the elimination within about 20 years of lymphatic other tropical diseases, has agreed to donate to WHO for
lariasis, one of the most painful and unpleasant of all its programme on control of tropical diseases sufcient
tropical diseases and simultaneously reduce the burden quantities of albendazole for as long as is necessary in
of other parasitic infections. order to eliminate the disease. The rm has also agreed
Lymphatic lariasis, a bloodborne disease transmit- to provide funds and human resources to help support the
ted by mosquitos, causes elephantiasis and male genital global elimination programme.
damage. It is a major social and economic scourge in the At the same time, Merck & Co., Inc., through Merck
tropics and subtropics of Africa, Asia, the Western Pacic Research Laboratories, has recognized that ivermectin is
and parts of the Americas, affecting over 120 million especially needed as part of the combination for treating
people in 73 countries. More than 1.1 billion people live lymphatic lariasis in Africa because of its overlap with
in areas where there is a risk of infection. onchocerciasis and loiasis, diseases for which commu-
In 1997, the World Health Assembly adopted a reso- nity-wide exposure to the alternative drug DEC may be
lution calling for the global elimination of the disease as unsafe. Merck is making ivermectin available for research
a public health problem, in view of rapid advances during programmes, some of which may be countrywide in scope,
the previous decade in diagnosis, clinical understanding, that will be carried out with WHO.
treatment and control, the successes of recent control Further support has come from the Arab Fund for Eco-
programmes, and increasing political commitment. nomic and Social Development, which will provide funding
The mainstay of WHOs elimination strategy is the for lariasis elimination in those of its member countries
use of simple, safe, inexpensive, conveniently delivered affected by the disease. The World Bank has strongly
drugs that kill the parasite. An additional benet is the endorsed this new global elimination programme.
simultaneous effectiveness of these medications against With encouragement and support from WHO, 13
other well-entrenched diseases such as intestinal worms, countries have now revised their national lariasis control
lice and scabies. strategies and plans of action to take advantage of the new
The available drugs are albendazole, diethylcarbamazine tools and approaches available. Seven of these countries
(DEC) and ivermectin. Once-yearly administration of single have already initiated national programmes. In India, the
doses of these drugs, given in 2-drug combinations, will largest, 40 million people were being targeted to receive
reduce parasite blood counts by 99% for a year or more. single-dose treatment on National Filariasis Day early in
Dramatic reductions in transmission have been docu- 1998. WHO will support all endemic countries with the
mented in highly endemic areas even in the rst year. necessary technical advice and assistance for developing
The success of the strategy has been made pos- implementation plans for treatment, monitoring, evaluation
sible by the commitment of pharmaceutical companies. and operational research.
The rst effective injectable vac- remains heavily affected and the dis-
cines against poliomyelitis were ease is still endemic in western and
introduced in 1955; since then the central Africa and some countries in
disease has gradually been eliminated the Eastern Mediterranean Region.
in much of the world. Reported cases In 1966, WHO estimated that
worldwide have declined by over 90% there were 10.5 million leprosy
since the campaign for global eradica- patients in the world with 1.8 mil-
tion by the year 2000 was launched in lion registered for treatment. WHO
1988. Polioviruses have disappeared developed and promoted multidrug
from the Americas, and the Western therapy, which it began to recom-
Pacic Region is rapidly becoming mend in 1981. Since then, over 8.4
polio-free. The Indian subcontinent million patients have been cured and
52
Measuring health
3.2 million in 1986 to 70 000 in 1997. per 1000 live births for every
The disease affects those living in district in the country)
the most rural parts of 18 countries
located in Africa south of the Sahara
and Yemen. Twenty-one formerly measles still kills about 1 million chil-
endemic countries have been certi- dren a year. In some countries, mostly
ed as free of dracunculiasis trans- in Africa, measles vaccine coverage
mission. is below 50%, which means that the
The outlook for lariasis control disease will continue to be epidemic
and elimination is such that an inter- there (Map 2).
national task force for disease eradica- Tetanus of the newborn is the
tion identied lariasis as one of only third killer of children after measles
six currently eradicable or potentially and pertusis among the six EPI vac-
eradicable diseases, and in 1997 the cine-preventable diseases and is a
World Health Assembly called for concern in all WHO regions except
the elimination of lymphatic lariasis Europe. Between 800 000 and 1
as a public health problem globally million newborns a year died from
(Box 8). The disease is of concern in tetanus in the early 1980s. An esti-
Africa, the Eastern Mediterranean, mated 730 000 such deaths are now
and South-East Asia. prevented every year, particularly
For the blinding disease tra- by targeting elimination efforts to
choma the target is elimination by high-risk areas. In 1997, there were
2020 through long-lasting antibiot- an estimated 275 000 deaths. WHO
ics. About 6 million people currently estimates that in 1995, about 90% of
alive in Africa and Asia have been neonatal tetanus cases occurred in
irreversibly blinded by it; another only 25 countries. The current status
152 million suffer from the disease of elimination of neonatal tetanus is
and need treatment. shown in Map 3.
Measles remains the leading killer Once also a target for eradication,
among vaccine-preventable diseases malaria remains a major threat. In
of children, and is still a concern in all 1954 there were 2.5 million deaths
six WHO regions. Despite excellent annually and 250 million cases world-
progress in recent years, particularly wide; now there are 1.5-2.7 million
in the Americas, where there is hope deaths and 300-500 million cases,
of eliminating it by the year 2000, 90% of them in tropical Africa, and
53
The World Health Report 1998
54
Measuring health
510%
a major human cancer. Following >10%
WHO recommendations, 90 coun- No data available
tries have now integrated it into their
national immunization programmes. very high prevalence of HCV infec-
By this means, the target is to reduce tion, especially in the developing
new HBV carriers in children by 80% world. In the United States an es-
by the year 2001. For many countries, timated 4 million people have con-
however, the major impediment to tracted the disease, four times more
the universal introduction of the vac- than HIV infection; approximately
cine has been its cost. Even at $ 0.50 30 000 new acute infections and
per dose, a three-dose series of vac- 8000-10 000 deaths occur each year;
cinations is more expensive than the it has also become the leading reason
combined cost of the other six EPI for liver transplantation. In France,
vaccines. WHO and UNICEF have 500 000-650 000 persons are infected,
developed a support strategy to help 3% of whom contracted the disease
the poorest and neediest countries to through blood transfusion. Australia
procure the vaccine. Implementation also reports a prevalence of HCV
of this strategy, and the achievement infection far greater than that of HIV
of high HBV coverage, could effec- infection. In Canada, at least half of
tively eliminate transmission of the hepatitis C cases are associated with
disease by the year 2025. the use of injectable drugs but the ac-
First identied in 1989, the hepa- tual proportion may be much greater;
titis C virus (HCV) has now be- it is also the leading reason for liver
come a major public health problem transplantation.
(Map 5). The incidence of HCV infec- Although HCV infection is not so
tion worldwide is not well known, but easily transmitted as hepatitis B or
from a review of published prevalence HIV infections, its tendency to induce
studies on HCV, WHO estimates that chronic liver disease in 50-80% of
3% of the world population is infected cases, leading to serious long-term
with HCV and around 170 million clinical sequelae, places it among
individuals are chronic carriers at the pathogens of major public health
risk of developing liver cirrhosis and concern. HCV is also characterized
liver cancer. In many countries par- by genetic diversity enabling it to
ticular population subgroups such escape the hosts immune system. In
as volunteer blood donors have a addition, the natural course of the
55
The World Health Report 1998
56
Measuring health
Of more than 9 million cancer ing seen at younger ages and more
cases newly diagnosed in 1997 world- frequently in countries as different as
wide, 52% occurred in the develop- Lebanon, and the United States. On
ing countries. For all countries, lung the basis of population ageing, it is
cancer was the most common in projected that the number of persons
men, followed in developed regions with schizophrenia will increase by
by prostate cancer, colorectal cancer 45% between 1985 and the year 2000.
and stomach cancer. In developing Social and environmental factors play
regions, stomach cancer is second, a role too, particularly in explaining
followed by liver cancer and cancer increases in alcohol and drug abuse,
of the oesophagus. In women, breast suicide, violence and other behav-
cancer is the most common in afuent ioural problems.
populations, followed by colorectal
cancer, lung cancer and stomach Emerging and re-emerging
cancer. In developing areas, breast AIDS has caused
cancer is also the most common, but diseases
cervical cancer is almost as common;
stomach cancer and colorectal cancer
The last 20 years have seen the
emergence of at least 20 new disease-
an estimated
are third and fourth respectively. The causing organisms around the world.
most remarkable changes in the rank-
ings compared to 10 years ago are the
Of these the human immunodecien- 11.7 million deaths
cy virus (HIV) which causes AIDS
steep upward trend of prostate cancer has had by far the most profound
(partly due to the introduction of early
detection programmes); the increase
global impact. An unknown disease since the epidemic
before 1981, AIDS has caused an
in breast cancer, especially in devel- estimated 11.7 million deaths since
oping countries; and the increase in the epidemic began. began.
lung cancer worldwide. Much of the Some of the other new diseases in-
upward trend in the last few decades clude Legionnaires disease, a form
in rich countries has been due to of potentially fatal pneumonia caused
tobacco smoking, a trend likely to be by bacteria which contaminate water
mirrored in coming years in develop- and air-conditioning systems, and the
ing countries, where smoking will also deadly Ebola haemorrhagic fever,
increase COPD deaths. which has been conned to countries
Population ageing, unhealthy di- in tropical Africa. Both were first
ets, obesity and a sedentary lifestyle identified in 1976, in the United
are the main factors that explain the States and the Democratic Republic
alarming upward trend in recent of the Congo respectively, and spo-
years in diabetes mellitus. There are radic outbreaks of both diseases have
about 143 million sufferers and this since occurred elsewhere. WHO has
number is projected to rise to almost played a leading role in the investiga-
300 million by the year 2025. tion and control of Ebola outbreaks.
Along with increased longevity Recent years have seen the reappear-
and socioeconomic development has ance of Rift Valley fever, caused by a
come an increase in some forms of virus rst isolated in 1931 in the Rift
mental disorder in the last two or Valley of Kenya but which has also ap-
three decades. Depression, schizo- peared in Egypt. At the end of 1997,
phrenia and dementia rates have WHO investigated a large outbreak
been rising, partly because more of the disease in north-eastern Kenya
people are living to an age where the and neighbouring Somalia.
risk of developing these disorders is There have also been sporadic
greater. Depression is also now be- outbreaks of monkeypox, a disease
57
The World Health Report 1998
Health expectancy
clinically similar to smallpox, in Africa For a long time, knowledge of life ex-
in the last 20 years. The smallpox pectancy at different ages, the infant
vaccine protected against both dis- mortality rate and the distribution
eases, but as vaccination stopped after of the causes of death according to
smallpox eradication in 1980, children the principal disease headings was
born since then are likely to be more sufcient to assess the health status
susceptible to monkeypox than their of populations and to determine
elders. The largest outbreak ever national public health priorities.
recorded occurred in the Democratic However, during the last 20 years
Republic of the Congo in 1996-1997, the need for a new type of indicator
involving more than 500 people, and has arisen as a result of changes such
was investigated by WHO specialists. as the lengthening of life expect-
While the natural host of some other ancy due to the fall in mortality at
infectious diseases remains unknown, older ages, and the issue of quality
there is strong evidence associating of the years lived, at very old ages
the new variant of Creutzfeldt-Ja- in particular. The former indicators
kob disease (nvCJD), a degenerative remains indispensable, as important
brain condition, with the consump- mortality inequalities still remain
tion of beef and other products from between countries and between the
cattle suffering from or infected by different groups making up popula-
the agent causing bovine spongi-form tions. As not much is known about
encephalopathy (Box 9). Because the limits of human longevity, health
there may be a latent period of many expectancy indicators which provide
years between infection and the ap- information on the populations func-
58
Measuring health
WHOs global surveillance activities rst identied human by WHO took over 1800 samples from birds and animals
infection with a new inuenza virus called A(H5N1) in Hong of 16 species to identify the natural reservoir of the virus
Kong in mid-1997 at one of the Organizations collaborat- and the extent of its spread in the animal population.
ing centres. The possibility that the outbreak heralded a WHO has for many years played a leading role as a
global inuenza pandemic did not materialize during the watchdog on the look-out for a pandemic, active in global
rst 10 months after the emergence of the virus among inuenza surveillance and in vaccine preparation. Every
humans, but the threat of a virus more easily transmitted February, experts review results from WHOs inuenza
between humans remains. network and make a recommendation on the antigenic
Sooner or later, however, such a pandemic will occur composition of the next years inuenza vaccine. WHO
and history shows that it must be taken with the utmost transmits this recommendation to health authorities and
seriousness. The WHO Network for Global Inuenza Sur- vaccine manufacturers.
veillance, which involves 110 national inuenza centres, Although the date of the next inuenza pandemic
therefore maintains constant vigilance. cannot be predicted, the certainty of its eventual arrival
New inuenza viruses to which nobody is immune means that pandemic emergency response plans have to
cross the barrier from animals to humans at unpredict- be prepared in advance. WHO has created a Task Force of
able times. These events can result in local epidemics, Experts on Inuenza whose members include the directors
but a few lead to global pandemics. Inuenza was rst of four main collaborating centres in Australia, Japan, the
described by Hippocrates in 412 BC and about 30 pos- United Kingdom and the United States, WHO staff and
sible pandemics have been documented in the last 400 representatives from three of the 110 national inuenza
years. Three have occurred in this century in 1918, centres which collaborate with WHO on surveillance.
1957 and 1968. The Task Force is developing a plan for the global man-
The 1918 pandemic of what was known as Spanish agement and control of a pandemic. The plan includes the
Flu was by far the most devastating, killing more than 20 promotion of high-growth seed virus for vaccine and the
million people worldwide between 1918 and 1920. The facilitation of vaccine production and international distribu-
virus responsible is believed to have originated in swine. tion and the dissemination of information, and logistic and
The pandemic occurred because the new virus was easily other support, to national health authorities. It calls for
transmitted from person to person. each of these authorities to develop its own emergency
Birds and poultry in particular are other sources of response to a pandemic.
inuenza viruses, and the A(H5N1) virus in Hong Kong The A(H5N1) outbreak in Hong Kong was the rst
infected chickens from a source or reservoir in nature one in which WHO pandemic planning was used, with the
that is still to be identied, before emerging in humans. step-by-step collection of information necessary to decide
Signicant person-to-person transmission of this virus whether or not a new vaccine was required. The outbreak
does not seem to have taken place. However, as a pre- also provided the opportunity to adjust the plan in line with
cautionary measure during the outbreak, the Hong Kong experience. In this way the scientic information necessary
authorities destroyed poultry ocks to eliminate the risk to make rational decisions on inuenza control is being
of further transmission, and a team of experts organized steadily accumulated.
tional state and on its vitality (levels order to assess whether the lengthen-
of activity and participation) as well ing of life expectancy is accompanied
as on its quality of life (level of felt or or not by an increase in time lived
perceived health) are well adapted in bad health. The concept of life
to the new conditions. expectancy has thus been extended
In recent years, the number of to morbidity and disability.
calculations of health expectancy The notion of health expectancy
(disability-free life expectancy, life was rst put forward in the United
expectancy in good perceived health, States in 1964 and a rst method of
etc.) has increased. They are used in calculation was proposed in 1971. In
59
The World Health Report 1998
Fig. 7. Evolution of life expectancy and expectancy
without severe disability, selected countries,
Fig. 7. Evolution of life expectancy and life expectancy without Since 1989, most researchers
males at age 65 working on the development of these
severe disability, selected countries, males at age
16 calculations have joined an interna-
tional research network called REVES
J
J J J J J J
(Rseau Esprance de Vie en Sant/
J J
Expected years
J
14 J J J J
J J J J J J J
X X
X
International Network on Health
J J X
J J
J J J
J J J J J
X X X X
X
X
X
X
Expectancy and the Disability Proc-
J J X
J
J J J J J J
X X X X X X
X
X
X
ess). Today, a rst estimate of health
12
X X X X X X
expectancy (generally a disability-free
X
X
X
life expectancy) is available for 48
X
countries. These indicators do not
10 make international direct compari-
1970 1975 1980 1985 1990 1993
sons possible, owing to the specic
Year characteristic of national health sur-
veys which provide the major part of
Australia
Severe disability-free life expectancy
the information used in the calcula-
Life expectancy 1984, a group of experts in the epide- tions. Most authors however now
France miology of ageing proposed to WHO
Severe disability-free life expectancy
distinguish between life expectancy
Life expectancy a general model of health transition without severe disability and life ex-
United States of America
J Severe disability-free life expectancy for computing health expectancy. pectancy without disability, all levels
J Life expectancy This model, which distinguished combined.
United Kingdom
X Severe disability-free life expectancy between total survival, disability-free Based on available information,
survival and survival without disabling Fig. 7 shows that life expectancy
LYT 98019
X Life expectancy
60
Health across the life span
Chapter 3
Health across the life span
T
his chapter looks at trends and treatable causes of death and illness
developments in health in infancy and childhood.
throughout the life span, deal- Overall reductions in under-5 and
ing with four specific age groups in- infant mortality are accelerating in
fants and small children; older chil- much of the world. However global,
dren and adolescents; adults up to regional and even national data often
the age of 65; and older people, with hide variations between and within
Childhood diseases a special focus on womens health. countries that are important for
health policies and programmes both
such as diphtheria, Infants and globally and locally. The fate of a child
is determined by its biology and its
small children environment. Its risk of dying is in-
fluenced biologically by its gender, its
scarlet fever and Viewed globally, the improvements natural defences and its nutrition; and
in infant and child health in the past by its physical, microbial, social and
50 years have been nothing less than cultural environments.
rheumatic heart spectacular, and appear likely to con- The living conditions of families,
tinue into the next century. For ex- the prevalence and modes of trans-
ample, 210 of every 1000 babies born mission of infectious disease agents
disease were in in 1955 died before their fifth birth- and the nutritional status of the child
day a total of 20.6 million deaths are among the strongest immediate
steady decline well in that year. By 1995 the death rate determinants that set the different
had fallen to 78 per 1000 (10.6 mil- levels of under-5 mortality rates
lion deaths) and should decline fur- around the world. Substantial im-
before vaccines ther to 37 per 1000 by 2025, when it provement in at least one, but pref-
is projected that the total deaths will erably all three of these elements is
be 5.1 million. required in order to effect a signifi-
and antibiotics In measuring the trends of the cant overall decline in the rates.
past 50 years, the reasons for both The decline in deaths among the
success and failure have to be under- under-5s in the developed countries
became widely stood in order to achieve further since the late 1940s is largely attrib-
progress and to eliminate the gross utable to improvements in sanitation,
disparities that persist between and water supply, housing, food supply
available. within countries. Three dimensions of and distribution and general hygiene.
health development need to be taken Childhood diseases such as diphthe-
into account: the epidemiological pat- ria, scarlet fever, and rheumatic heart
terns of disease and deficiencies disease were in steady decline well
including the interactions of diseases before vaccines and antibiotics be-
and deficiencies and the mortality lev- came widely available.
els; the social, economic and health A similar decline in specific dis-
infrastructure; and the priority strat- eases is occurring now in the devel-
egies and adequacy of the actions oping world, mainly as a consequence
taken to address the preventable and of general improvements in sanita-
61
The World Health Report 1998
tion, water supply, education and ac- the toll of 21 million such deaths in
cess to preventive and curative health 1955, it remains unacceptably high. In
care in the community. These im- the developing world in 1995, about
provements are similar to those that 7.5 million of these children died from
took place in the developed econo- one or, frequently, more than one of
mies of Europe and North America five conditions: malaria, malnutrition,
50-80 years ago. However, progress measles, acute respiratory infections
has been more rapid due to the his- and diarrhoea (Fig. 8). Other major
torical lessons learned and the advent causes are related to pregnancy and
of new knowledge and technologies childbirth, sepsis, neonatal tetanus and
that influence prevention, treatment, AIDS. Often it is impossible to know
nutrition and fertility regulation. which actually killed the child, because
Unfortunately, the progress re- of difficulties in distinguishing the
corded is not the full picture. Many signs and symptoms of some of these
countries the least developed have diseases from one another. In many of
been unable to make or sustain simi- the least developed countries, the odds
lar progress over the years. In a few are still heavily stacked against the
countries, child mortality levels are childs survival.
still above 200 per 1000 live births, The everyday nature of these
and in others the levels are declining deaths disguises the complex se-
slowly, at a rate of no more than quence of events leading to them
1-2% per year. the remorseless process of repeated
About 10 million children born in episodes of infections, often sequen-
1997 will die before reaching their fifth tial, not infrequently concurrent.
birthday. Although this is barely half Each episode is accompanied by loss
of appetite and decreased food intake,
and each time the illness itself makes
Fig. 8. Main causes of death among children under age 5, increased demands on the childs en-
developing world, 1995 a ergy. Local health care facilities, if
Malnutrition (excl. IUGR) 0.3 (100%) they exist, may be ill-equipped and
Neonatal tetanus 0.4 (20%) poorly supplied, and inadequately
Birth trauma 0.4 (30%)
Neonatal sepsis and staffed, with patterns of care that are
meningitis 0.4 (30%) rarely optimal and may even be harm-
Diarrhoea 2.0 (70%) Congenital anomalies 0.5 (30%)
ful. Often, the child struggles for life
in a highly crowded, unhygienic and
Birth asphyxia 0.9 (35%)
poorly ventilated environment that
facilitates the transmission of respi-
All other causes 0.2 (40%)
Measles 1.1 (65%)
ratory infections and malaria.
Malaria 0.7 (40%)
The tragedy is that most of these
Tuberculosis 0.1 (60%)
deaths in the under-5s could be pre-
Pertussis 0.4 (50%)
vented and the conditions treated
Prematurity 1.0 (40%) within the resources of most, although
not all, countries. The greatest posi-
Malnutrition associated
ALRI 2.1 (44.1%) tive impact on child mortality results
Total deaths: 10.4 million from a combination of immunization,
Disease clusters improved maternal health, family
Neonatal and perinatal causes. Neonatal tetanus, birth trauma, neonatal sepsis and planning, and improved nutrition in-
meningitis, congenital anomalies, birth asphyxia, prematurity.
terventions that affect nutritional sta-
Integrated management of childhood illness. Malaria, acute lower respiratory
infection (ALRI), measles, diarrhoea, malnutrition. tus and prevent or provide effective
treatment for the common infectious
LYT 98002
a
Number of deaths in millions followed by % malnutrition-associated deaths in brackets. diseases of childhood.
62
Health across the life span
Infant mortality rates are com- Fig. 9. Causes of neonatal death, 1995
posed of two biologically and
epidemiologically distinct compo-
nents. The first is neonatal mortality, Other
which is largely influenced by the Congenital 5%
anomalies
health and care of the mother before 10% Infections
and during pregnancy and during 34%
delivery, and the care of the infant in Problems linked with
the postpartum period. The second preterm birth
is the postneonatal period, which is 23%
largely affected by environmental fac- Asphyxia/trauma
tors, feeding and other aspects of 28%
care. Historically, infant mortality
rates are declining from previously
LYT 98015
high levels, even in the absence of
specific technical interventions.
Neonatal mortality refers to
deaths of infants between birth and ever, at least 4 out of 5 newborn
the seventh day of life the early deaths are due to infection, birth as-
neonatal period; and from the 8th to phyxia, birth injury and problems
the 28th day of life the late neonatal linked to preterm birth (Fig. 9). Con-
period. genital anomalies, usually thought to
Perinatal mortality refers to be the main cause of death in babies,
deaths of babies after 22 completed account for a relatively small percent-
weeks of gestation, during birth and age of these deaths. Helping these
during the first seven days of life babies to survive and grow up into
the perinatal period. Fetal death or healthy adults does not require ex-
stillbirth is death prior to the com- pensive technology. Good newborn
plete expulsion or extraction from the care at birth does not require sophis-
mother of the fetus, irrespective of ticated equipment; it calls for a set of
the duration of pregnancy. simple preventive measures and a lit-
About 9 million babies are either tle prompt extra care (Box 11).
born dead or are born alive only to WHOs Mother-Baby package lists
Box 11. Essential newborn
die within their first 28 days of life. straightforward and simple interven- care
While the causes of about 4 million tions at various stages of pregnancy,
stillbirths occurring worldwide are and during and after birth, that are All newborn babies need basic
difficult to assess, research shows that known to improve the health and save care: cleanliness, warmth, early
nearly half of all stillborn babies have the lives of mothers and babies. and exclusive breast-feeding, eye
died as a result of maternal compli- care, immunization, resuscitation
cations during labour and delivery. when necessary.
Many stillborn babies would have
Controlling childhood Some newborns need special
been perfectly normal infants if ap- diseases through care: sick newborns need early
propriate care had been given at birth. immunization recognition of danger signs,
The longer the baby survives, the prompt treatment.
more likely it is that the death will be The world continues to underuse the Preterm and low birth weight
due to causes other than those related most cost-effective public health in- infants need more cleanliness,
to pregnancy and delivery. More than tervention of all immunization. It is more warmth, more attention to
two-thirds of the nearly 4.8 million unacceptable that at least 2 million breast-feeding, more effective rec-
newborn deaths are among fully de- children still die each year from dis- ognition and treatment of infec-
veloped babies born at term and ap- eases for which vaccines are available tions.
parently well equipped for life; how- at low cost. Immunization has been
63
The World Health Report 1998
responsible for the most dramatic age is variable. There are frequently
changes in child health in the last few pockets of low coverage, especially
decades. Vaccines have prevented among the urban poor, where chil-
death, disease and disablement among dren are in frequent contact with
hundreds of millions of children. each other and easily transmit dis-
In 1948, immunization pro- ease. Many years have elapsed be-
grammes were largely restricted to tween the invention of vaccines and
industrialized countries, and even their widespread use today in immu-
then were often partially imple- nization programmes. Fortunately,
mented. It was not until the forma- the interval between successful field
tion of WHOs Expanded Programme trials and large-scale application is
on Immunization in 1974, when less shortening. It took smallpox nearly
than 5% of children were being im- two centuries to be eradicated. But
munized, that developing countries after 35-40 years, polio is well on the
began to create national schedules way to eradication, and it is only
It took smallpox and programmes. Now, only around about 30 years since measles immu-
20% of the worlds children remain nization began (Box 12).
unimmunized. First smallpox was Large epidemics of poliomyeli-
nearly two centuries eradicated. Since then, as coverage tis occurred regularly in the 1950s in
for each of the childhood vaccines all industrialized countries, causing
rose, disease incidence fell. Large panic among parents and crippling
to be eradicated. outbreaks previously experienced in thousands of children every summer.
almost every country are now less fre- Following the development and wide-
quent and of lower intensity. spread routine use of anti-polio
But after 35-40 From 1981 there was a fourfold vaccines, the disease rapidly disap-
increase from approximately 20% to peared in industrialized countries and
years, polio is well reach the 1990 goal of 80% immuni- was eliminated as a public health
zation coverage among infants world- problem there in the early 1960s.
wide with BCG, measles, and the However, epidemic poliomyelitis con-
on the way third dose of DPT (diphtheria, per- tinued to be a major public health
tussis, tetanus) and oral poliovirus problem in most developing coun-
vaccines. An estimated 3 million tries. The incidence of paralytic po-
to eradication. young lives were saved from measles, lio in the developing world began to
neonatal tetanus and pertussis in 1990 decrease only after routine immuni-
alone. By 1995, over 80% of the zation of infants with oral polio vac-
worlds children had been immunized cine (OPV) in the late 1970s.
against diphtheria, tetanus, whooping Virtually all endemic countries in
cough, poliomyelitis, measles and tu- the world have now begun to imple-
berculosis. During 1995, in addition ment the WHO-recommended strat-
to the 500 million routine immuniza- egies to eradicate polio supplemen-
tion contacts with children under 1 tary mass immunization with OPV
year of age, a record 300 million chil- and surveillance for acute flaccid pa-
dren throughout the world almost ralysis. Polio has been eradicated
half of those under the age of 5 were from the Americas since 1991, and is
immunized during mass campaigns on the verge of eradication in Europe
against polio. and the Western Pacific. The major
Despite these successes, children reservoirs of wild virus transmission
are still slipping through the safety are in South Asia and sub-Saharan
net. For example, even though glo- Africa, although eradication activities
bally 80% of children are immunized are progressing in virtually all en-
against measles, vaccination cover- demic countries of these regions.
64
Health across the life span
During national immunization
days in 1997, supplemental OPV was Box 12. Eradicating measles through immunization
provided to almost two-thirds of the
worlds children under 5, that is to Based on implementation of a combination of measles immunization and
more than 400 million children. To surveillance strategies, countries are considered to be in one of three stages:
monitor progress towards eradication, Control. Reduction of incidence and/or prevalence to an acceptable level
establishing and improving surveil- as a result of deliberate efforts, requiring continued control measures.
lance for acute flaccid paralysis has The objective is to achieve high routine coverage with one dose of mea-
now become an urgent priority. The sles vaccine among infants to reduce measles morbidity and mortality.
development of systems for the sur- Outbreak prevention. Aggressive immunization strategies have prevented
veillance of flaccid paralysis often lags forecasted measles outbreaks.
behind the implementation of na-
Elimination. Reduction of incidence to zero as a result of deliberate ef-
tional immunization days, and major
forts, requiring continued control measures.
efforts are needed in many countries
to increase the quality of such surveil- In the Americas, WHO has implemented a periodic mass immunization
lance. strategy combined with strengthening of surveillance to interrupt measles
Countries with the lowest immu- transmission and eliminate the disease by the year 2000. Other regions and
nization coverage are nearly always countries have implemented or are considering the implementation of strat-
countries with internal conflicts. In- egies aimed at interrupting measles virus transmission. Recently, the WHO
frastructures are weakened or de- Eastern Mediterranean Region has pledged to eliminate measles by the year
stroyed, resulting in large numbers of 2010, and the European Region is planning to do so by the year 2007. In the
children remaining unimmunized future, the sum of all regional efforts towards elimination will result in the
and in outbreaks of vaccine-prevent- global eradication of measles, obviating the need for further control meas-
able diseases. Intense efforts to ac- ures.
celerate polio eradication in such cir- From 1977 to 1990, the global reported coverage with one dose of
cumstances include using such tech- measles vaccine administered through routine services increased from ap-
niques as days of tranquillity when proximately 5% to 80%, and then remained stable at that level until 1996.
fighting stops to allow immunization The results of recently published studies indicate that the current WHO
to take place. Polio-free countries and policy of offering vitamin A at the same time as measles vaccine to 9-month-
areas are increasingly at risk of rein- old infants is appropriate, safe and effective. The benefit of administering
fection from countries which remain vitamin A in cases of measles at any age has never been questioned and
endemic; should this occur, it will continues to be recommended by WHO as part of the integrated manage-
delay the global eradication goal. The ment of childhood illness.
full benefits of global eradication will Despite the widespread availability of safe and effective measles vaccines
be realized only when polio has been since 1963, measles still accounts for 10% of the global mortality from all
eradicated from the most remote ar- causes among children aged under 5 years. Although measles eradication is
eas of all countries. Eradication by the technically feasible, programmatic, political and financial obstacles must be
year 2000 or soon thereafter remains overcome before the goal of eradication can be achieved.
feasible, provided that adequate ad-
ditional funding is made available and
the current momentum of polio
eradication activities can be main- the United Kingdom demonstrated
tained. that high-level measles control and
By 1996, estimated measles mor- even interruption of transmission is
bidity and mortality worldwide had feasible over large geographical areas.
fallen by 78% and 88%, respectively The evaluation of these country and
compared to the pre-vaccine era. regional elimination strategies will
During the 1990s, the widespread use provide valuable information for de-
of innovative measles control strate- veloping a global measles eradication
gies in the Americas and countries as strategy. While the current measles
diverse as Mongolia, South Africa and vaccine is one of the safest, most ef-
65
The World Health Report 1998
fective and cost-effective vaccines for the treatment of acute diarrhoea
ever developed, plans are in hand to in children under 5. They also showed
develop a more heat-stable vaccine that children treated with ORT and
which could be used in mass cam- feeding actually gained weight. Re-
paigns, would not need the cold chain search in different countries con-
and could be administered without firmed the benefits and safety of ORT.
needle and syringe. Based on this information, WHO pro-
Tetanus of the newborn is the moted the wide use of ORT to reduce
third killer of children after measles mortality from the acute diarrhoea
and pertussis among the six EPI vac- and associated malnutrition that was
cine-preventable diseases. While at the time claiming the lives of over
between 800 000 and 1 million 5 million children per year. In 1978,
newborns died from tetanus in the a new programme was established,
early 1980s, an estimated 730 000 combining research with the devel-
such deaths are now prevented every opment of materials and support to
The simplified year, particularly by targeting elimi- establishing programmes in coun-
nation efforts to high-risk areas. In tries. In collaboration with UNICEF
1997, there were an estimated and numerous bilateral agencies,
standard case 275 000 deaths. WHO assisted over 100 Member
Diphtheria is a respiratory infec- States to set up national programmes,
tion transmitted through close physi- define policy, plan activities and train
management became cal contact, especially in overcrowded health workers. By the mid-1990s,
and poor socioeconomic conditions. virtually all health workers were
the basis of WHOs In 1990, a large outbreak of diphthe- aware of ORT, even if they had not
ria occurred in the Russian Federa- been trained in its use. Fewer dehy-
tion and by the end of 1994, it had drated children were seen at health
efforts to reduce spread to all the newly independent facilities as families learned to in-
States. At least 90% of all diphtheria crease fluids and keep feeding chil-
cases reported worldwide during dren who were suffering from diar-
pneumonia mortality. 1990-1995 were in these countries. rhoea. Exclusive and prolonged
The epidemic appears to be waning breast-feeding was also found to be
after massive immunization. This epi- an effective, feasible intervention to
demic serves as a reminder of the dan- prevent diarrhoea.
ger of not maintaining immunization lev- In the late 1980s it was shown that
els in a community. acute respiratory infections, mainly
pneumonia, were the major killers of
Acute respiratory children aged under 5. Access to tech-
nology or expertise was limited, and
infections and diarrhoea many pneumonia cases went un-
In the late 1960s, WHO scientists treated. At the same time, children
noted exciting developments in the suffering from simple coughs and
treatment of cholera, in particular the colds sometimes received antibiotics
treatment of patients using oral rehy- unnecessarily. Based on a simple ap-
dration therapy (ORT), which de- proach to pneumonia detection de-
pended on a solution made by dissolv- veloped in the early 1980s at a col-
ing dried salts in clean water, and laborating centre in Papua New
avoided using expensive and hard-to- Guinea, WHO developed and vali-
transport intravenous fluids. Field tri- dated guidelines, and established a
als determined that it was feasible for programme in 1984. The simplified
peripheral health workers to use ORT standard case management became
the basis of WHOs efforts to reduce
66
Health across the life span
pneumonia mortality. Since then, the it may be possible to target antibiot-
Organization has developed guide- ics more effectively to only those chil-
lines, tools and supportive technical dren who will really benefit from
documents for clinical management them. Current efforts are aimed at the
training, programme management first-level health facility, but it is es-
and evaluation. Following a general sential to convince the population of
trend towards integration, the pro- the need for urgent medical attention
grammes for control of diarrhoeal dis- when children are sick.
eases and for acute respiratory infec- In addition, complementary strat-
tions were merged in 1990. egies for the prevention of some of
these diseases are also being pro-
Integrated management moted and supported. For example,
for reducing the incidence of diar-
of childhood illness rhoea, they include promotion of op-
At the same time, research involving timal breast-feeding practices and of
childhood diseases made it clear that the baby-friendly hospital initiative, Research involving
single-disease approaches may not be modifying complementary feeding
practices, improving water supply and
the best for the child. A child does
sanitation facilities and promoting childhood diseases
not arrive at the health facility as a
case of something, but arrives sick, personal and domestic hygiene. Ad-
equate breast-feeding in a large
and may have several conditions at
number of settings is found to be as-
made it clear that
once. In some instances, the mother
may bring the child in for a problem sociated with a 2.5-4-fold lower rate
which may only be a minor manifes- of mortality and less severe cholera single-disease
tation of a dangerous illness. By 1990, and Shigella spp. infections. In re-
it was well documented that most spect of malaria, they include use of
childhood deaths were caused by five impregnated bednets which, even in approaches may not
conditions: as many as 70% of deaths the short term, have resulted in a 17-
could be attributed to diarrhoea, 30% reduction in total malaria deaths
pneumonia, measles, malaria and in young children. For measles, im- be the best
malnutrition. The need for integra- munization of infants has been an ef-
tion at health facilities to rationalize fective intervention for reducing in-
the task of health workers became in- cidence. for the child.
creasingly evident. In 1992, WHO
and UNICEF worked out clinical Low birth weight and
guidelines that integrated all five con- nutritional deficiencies
ditions. The resulting strategy is
called integrated management of Low birth weight is defined as a
childhood illness. Research continues weight at birth of less than 2500 g
to improve integrated case manage- (i.e. up to and including 2499 g), ir-
ment and to identify more compre- respective of gestational age. It has
hensive disease prevention activities, an adverse effect on child survival
including the development and adop- and development, and may even be
tion of new vaccines. an important risk factor for a number
In the view of WHO, although the of adult diseases, including non-in-
formula for ORS is satisfactory, there sulin-dependent diabetes and heart
may be an even better one. Experi- disease. While it is recognized that
ence in the field suggests that the the etiology of low birth weight is
process of detecting and managing multifactorial, emphasis is given to
pneumonia may need to be reviewed; those maternal factors that are be-
67
The World Health Report 1998
Map 6. Underweight prevalence among preschool children, risk of dying from diarrhoeal diseases,
1995 estimates acute respiratory infections and, if not
immunized, measles. They are more
likely to be malnourished at 1 year.
By the age of around 5, the low-birth-
weight child, probably having had
more cyclic episodes of infection and
malnutrition, may be severely stunted
(Map 6). This growth deficiency will
be carried into adult life and trans-
lated into reduced work output, and
often impaired learning ability.
Globally, WHO estimates that 25
million low-birth-weight infants are
Proportion of born each year, constituting 17% of
children under 5
<10% all live births, nearly 95% of them in
1019% the developing world. The incidence
2029% WHO 98065
68
Health across the life span
sub-optimal breast-feeding practice, fected by protein-energy malnutri-
they are at increased risk of protein- tion; 76% of these children live in
energy malnutrition. Breast-feeding Asia (mainly southern Asia), 21% in
is one of the most effective, low-cost Africa and 3% in Latin America. As
interventions for neonatal health. many as 206 million children in de-
Nothing but breast milk is required veloping countries are stunted (stunt-
for the first 4-6 months of life, nei- ing is associated with poor develop-
ther substitutes, nor supplements, nor mental attainment in children and
even water. Even in developed coun- functional impairment in adults). Ef-
tries breast-feeding lowers the rate of forts to accelerate economic develop-
respiratory and gastrointestinal illness ment significantly will be unsuccess-
to one-fourth that of non-breast-fed ful until optimal child growth and de-
infants. velopment are ensured.
Despite this knowledge, many Iodine deficiency has been de-
hospitals and health workers continue scribed as the worlds single most sig-
to obstruct breast-feeding or fail to nificant cause of preventable brain In most countries
recommend it. Putting the infant to damage and mental retardation. Io-
the breast just after birth decreases dine deficiency disorders affect about
the risk of hypoglycaemia, eliminates 14% of the world population, and 834 of the world, the
the need for prelacteal glucose water million people are affected by goitre.
and hastens the onset of full lactation. Iodine deficiency in the fetus, due to
Allowing mother and infant to stay inadequate iodine status of the
duration of breast-
together 24 hours a day, with on-de- mother, is associated with a greater
mand feeding, improves health and incidence of stillbirths, spontaneous feeding is declining
reduces the risk of disease even in the abortions, congenital abnormalities,
newborn period. Such a feeding pat- low birth weight, infant and child
tern eliminates the epidemics of mortality, and may lead to cretinism. or shows no change.
pathogenic E. coli and staphylococ- The IQ scores of iodine-deficient chil-
cal infections that used to sweep dren and adults are lower than those
through newborn nurseries and elimi- of people who are not iodine-deficient.
nates the fatal necrotizing enterocolitis Significant improvement in mental
among very low-birth-weight babies. development, school performance and
WHO estimates that globally, ex- motor development have been dem-
clusive breast-feeding rates remain onstrated with iodine supplementation
low. An estimated 35% of infants are of primary school children.
fed only breast milk at some point Childhood obesity and its conse-
between birth and four months of quences are emerging as a global prob-
age. As awareness of the advantages lem. Data from 79 developing coun-
grows in both developing and devel- tries and a number of industrialized
oped countries, more Member States countries suggest that, by WHO stand-
are taking steps to protect and pro- ards (>+2 standard deviations above
mote breast-feeding, and rates are the reference median weight for
increasing. All too often, however, in height), about 22 million children aged
countries where malnutrition and under 5 are overweight. Obesity af-
mortality are high, these rates remain fects almost 10% of schoolchildren in
low. Many countries (especially in industrialized countries and high rates
Europe) continue to have low breast- are also emerging in some of the de-
feeding rates, although they are slowly veloping ones. Some 30% of obese
improving. children become obese adults.
WHO estimates that about one- Obesity is also a significant risk
third of the worlds children are af- factor for a range of serious non-
69
The World Health Report 1998
communicable diseases and condi- non-epidemic years, at least 1 million
tions. WHO has initiated a review of cases of bacterial meningitis are esti-
associated morbidity and mortality mated to occur and about 135 000
with a view to developing guidelines children die. About 300 000 of these
for Member States on obesity preven- cases and 30 000 deaths are due to
tion and management. Improved pre- meningococcal meningitis. In epi-
vention of and therapy for childhood demic years the number of cases of
obesity are the most cost-effective meningococcal meningitis may dou-
approaches to reduce morbidity and ble to 600 000 or more, with 60 000
mortality due to obesity in adulthood; or more deaths.
three potential approaches for the Asthma, a disorder of the airways,
preventive interventions to deal with is one of the most common chronic
this problem are reduction in dietary diseases worldwide, with a prevalence
energy intake, increase in the energy rate among children ranging from
spent on activity and reduction in in- 1.5% to over 12%. Rates are gener-
The long-term activity. Children with potentially le- ally lower in developing countries but
thal complications of obesity such as globally both prevalence and hospi-
sleep apnoea require rapid and sus- talization rates have increased by 40%
prognosis of tained weight reduction. One possi- in the last decade. The long-term
ble approach in children is a carbo- prognosis of childhood asthma is now
hydrate-free diet under careful moni- a major concern. It has often been
childhood asthma toring and follow-up. The role of suggested that childhood asthma will
drugs in the treatment of obesity is not disappear when the patient reaches
is now a clear. Some interventions aimed at adulthood. Epidemiological evidence
both parents and children have been is less optimistic. It has been esti-
successful (e.g. modifications in diet, mated that 30-50% of children have
major concern. lifestyle activities and behaviour). asthma that disappears at puberty but
often reappears in adult life. Be-
Other childhood diseases of tween one-third and two-thirds of
children with asthma continue to suf-
public health concern fer from the disease through puberty
Rheumatic fever and rheumatic and adulthood. Asthma in childhood
heart disease (the most common is an example of a chronic disease
cardiovascular disease in children and which can impair childrens
young adults) are examples of how socialization, school performance and
social and economic factors, and later later life. Self-management and care
health care and medical technologies, are essential if the asthmatic child is
have contributed to and then accel- to lead as normal a life as possible.
erated the decline of a disease that Paediatric AIDS is substantially
was epidemic in developed countries underrecognized and underreported,
a century ago. Limited evidence sug- because of difficulties in establishing
gests that there has been little if any the diagnosis of HIV infection in in-
decline in the occurrence of rheu- fancy, as well as clinical features over-
matic heart disease in developing lapping with those of the other severe
countries over the past few decades. diseases of childhood. In 1997, about
Meningococcal meningitis oc- 95% of the estimated number of
curs in all parts of the world. In the AIDS deaths in children under 15
1980s an epidemic wave of meningo- occurred in the under-5 age group.
coccal meningitis spread over vast Perinatal transmission has been well
territories in Asia and Africa. Even in documented, with 15-35% of children
of HIV-positive mothers being in-
70
Health across the life span
fected and accounting for the major- propriate care, including prevention.
ity of children with AIDS. As almost The common infectious diseases
half of all newly infected adults are of childhood are coming under con-
now women, WHO projects that if trol through a combination of health
current trends continue, by the year promotion, prevention and simplified
2000, over 13 million women will standard treatment regimens. But at
have been infected and 4 million will the same time, the healthy growth
have died of AIDS. Their uninfected and development of many children is
infants will constitute a growing group threatened by very rapid, often dis-
of potential orphans, since most of ruptive social, cultural and economic
their HIV-infected mothers will die changes. The emerging new morbid-
of AIDS within 5-10 years of their ity is mainly of a psychosocial nature
birth. By the year 2000 as many as 10 with a very low mortality rate, except
million children under 10 may be or- from suicide. It is of increasing im-
phaned as a result of maternal AIDS portance worldwide: very common in
in sub-Saharan Africa alone, and pro- the developed world, and not rare in The healthy growth
jected infant and child deaths from the developing one. A more refined
AIDS may increase child mortality approach to disease problems is badly
rates by as much as 50% in parts of needed, since prevention and care and development
sub-Saharan Africa. But the most should adapt to this interacting proc-
alarming trends of HIV infection are ess. Globally, the new morbidity is
in South-East Asia. In some high- strongly associated with behavioural
of many children
prevalence communities, AIDS is al- problems and is therefore much
ready starting to reverse the long- more difficult to prevent than the is threatened by
term effects of child health initiatives. diseases that have been known for
Many women are at particularly high centuries. Countries in an interme-
risk of infection because of their low diate state of socioeconomic devel- very rapid, often
socioeconomic status, their difficult opment are accumulating classical
living situations and/or the fact that and new morbidity and are facing
they do not have access to AIDS pre- great difficulties as regards the care disruptive social,
vention information. Paediatric AIDS of the sick.
will increase accordingly. In terms of emerging morbidity,
AIDS represents the most crucial cultural and
Emerging public challenge because of its impact on
women, children and families. How-
health priorities ever, other problems should not be economic changes.
Although mortality statistics are be- overlooked: substance abuse during
coming more reliable, little is still pregnancy with its harmful effects on
known concerning morbidity of chil- both mother and child, and acciden-
dren in different settings. It is crucial tal injuries, by far the first cause of
to get accurate data or at least esti- potential years of life lost. Accidental
mates of morbidity in order to injuries are only one of the ill-effects
train personnel, to prepare relevant of violence: if other causes are added
programmes and services and to such as child abuse and neglect, vio-
evaluate their performance. The on- lent morbidity is becoming more of
going epidemiological transition in a burden. Child abuse and neglect
the developing world makes it even include four distinct conditions:
more important to target morbidity physical abuse, neglect, emotional
in order to be successful in combat- abuse and sexual abuse. They occur
ing childhood diseases through ap- within and outside family settings, in
the latter case sometimes in an insti-
71
The World Health Report 1998
tutional or non-institutional setting.
Box 13. Healthy child development Child abuse mortality rates for infants
in most countries are estimated at
Child development concerns not merely physical health but also the process around 7 per 100 000 live births, pro-
of change whereby a child learns to handle ever more difficult levels of mov- viding a rough global estimate and
ing, thinking, speaking, and relating to others. In its first year of life, the indicating only the tip of the ice-
infant needs to develop a sense of trust in the world. A consistently nurturing berg. Although childhood accidents,
and tension-free environment provides the infant with a sense of security. injuries and disabilities have been rec-
This critical process is usually achieved by 13 months of age. ognized as a major problem, mean-
Unfortunately the health sector, not always appreciating the life-long im- ingful estimates of their incidence
pact of the interactions of nutrition, child care and nurturing on cognitive and worldwide are not available. Greater
social development, has done little to foster parenting and child care beyond medical knowledge and better tech-
meeting the survival and physical needs of children. Where child develop- nology mean that more children sur-
ment programmes exist, they usually start at the already late age of 3 or 4 vive premature birth, congenital mal-
years. formation, accidents, injuries and ma-
The best child development programmes are aimed at strengthening the lignant diseases. Their survival is of-
capacity of mothers, through home visiting and child stimulation from infancy ten not free of disability.
until the age of 3. Early child stimulation interventions within the first year of Increasing environmental haz-
life have their greatest impact on the most disadvantaged groups and ards add their toll to this new pat-
populations, attenuating the effects of poverty, severe malnutrition, low birth tern of disease, sometimes aggravat-
weight and prematurity. ing pre-existing ill-health, such as
Research shows clearly the intimate linkages between physical growth asthma, sometimes directly responsi-
and psychological development, and the powerful relationships among growth, ble for acute or chronic impairments
development, health, and care-giving. The mechanisms that promote physi- (toxic, allergic), e.g. lead poisoning in
cal and mental development are not unidirectional from care-givers to chil- childhood. With the epidemiological
dren; in fact it is the interaction between the two that is critical. Better- transition, some countries are simul-
nourished children tend to be more active and able to explore the environ- taneously facing the burden of classi-
ment and elicit more interaction from parents, and may be more effective in cal infancy and childhood diseases,
demanding and getting food. In addition, the care-giving activities within the which is not yet solved, and the bur-
home that affect child nutrition and psychosocial development are closely den of this new morbidity. They need
related: a major part of giving care to infants and toddlers is simply feeding. specific flexible strategies in planning
Many households in conditions of poverty still have the resources to pro- for health services and in care, deliv-
vide adequate diets for children and to use good feeding practices. However, ery and the allocation of scarce re-
they need the knowledge and skills to do so. Families who are severely con- sources both human and material.
strained economically will also need access to food and dietary supplements. With increasing and rapid urbani-
Finally, families need help in improving the interactions between care-giver zation, developmental deprivation
and child, especially the malnourished child. of young children is becoming a ma-
In general, progress in child health and development will remain jor issue (Box 13). The urban envi-
frustratingly slow if the national and international health bodies focus only on ronment can be particularly hostile to
the medical model of public health strategies directed at the one in 13 chil- children. Density of human popula-
dren in the developing world who die before reaching the first year of life. It is tion, accompanied by a lack of basic
the legacy of malnutrition, continuous non-fatal illness, and lack of social and urban services, results in increasing
environmental stimulation to development that perpetuates the health and environmental health risks. Poor
social deficits that are transmitted to the next generation, repeating the housing, lack of parental supervision
statistical pattern of one in 13 dying, but 12 of 13 surviving in misery and and even abandonment, early child-
with prospects of a blighted future. hood labour and other consequences
of urban poverty are endemic and
contribute to high morbidity and
mortality among children. There are
limited recreational facilities. Chil-
dren, particularly those in single-
72
Health across the life span
parent families where the parent of-
ten has to work long and irregular Box 14. The deadly deficiency of vitamin A
hours outside the home, suffer from
cultural deprivation and face a con- Vitamin A deficiency affects as many as 256 million children in more than 75
flict of value systems, which further countries and is the worlds most preventable cause of blindness. Of some
contributes to psychosocial difficul- 2.7 million preschool-age children who have eye damage resulting from this
ties. A significant proportion of urban deficiency, an estimated 350 000 go blind every year, and up to 60% die
households is headed by women who within a few months of becoming blind.
in many cases do not have any close Vitamin A deficiency is also linked with an increase in the severity of
relatives living nearby, and the nature infections, particularly measles and diarrhoeal disease. Through synergism
of the areas in which they live does with measles infection, vitamin A deficiency contributes to some extent to
not foster the development of other the estimated 960 000 childhood deaths from measles every year. The ef-
links as alternative support. fect on mortality is pronounced for diarrhoeal disease, is demonstrable for
Children are the most vulnerable deaths attributed to measles, and very small or maybe absent for deaths
members of society in times of armed attributed to respiratory disease.
conflicts. In the past decade around This conclusion is based on a meta-analysis of 10 controlled mortality
2 million children have died as a re- trials in populations where xerophthalmia (the eye condition caused by vita-
sult of war and many times that min A deficiency) is present. The review by the same authors of 17 studies
number have been displaced from providing information about morbidity outcomes, including morbidity results
their homes. In such conflicts, deaths from the 10 mortality trials, finds very little evidence to suggest that vitamin
of children are up to 24 times greater A status affects the prevalence of general morbidity in young children.
than in times of peace. At present Deficiency occurs where diets contain insufficient vitamin A for the basic
there may be more than 4 million needs of growth and development, for physiological functions, and for peri-
children in the world who have been ods of added stress due to illness. In areas where vitamin A deficiency oc-
disabled because of armed conflict, curs, women of childbearing age are at high risk of its consequences be-
many by landmines. cause they need more of the vitamin during pregnancy and lactation.
The number of adult diseases that Infants who are born depleted of vitamin A need more of this vitamin than
have their roots in childhood include can be supplied through their mothers milk after 4-6 months of nursing if
those that have a strong nutrition-di- they are to be prevented from developing deficiency.
etary component. Deficiency dis- Improvement in vitamin A status may reduce the chance of infectious
eases need to be diagnosed and pre- diseases progressing to their severe forms. Improving the vitamin A status
vented in childhood. Protein-energy of deficient children and treating cases of measles with vitamin A can sub-
deficiency and specific nutritional stantially reduce childhood morbidity and mortality.
deficiencies have been eliminated in Supplementation with vitamin A has been shown to be effective in reduc-
many parts of the world but some ing mortality by as much as 23% from these conditions in areas where
populations are still much affected. deficiency is common. The results of studies in Ghana and Brazil indicate
Specific examples with long-term ad- that vitamin A supplementation is associated with a decrease in the severity
verse effects are iodine deficiency of infectious diseases.
disorders, vitamin A deficiency (Box Recent findings have indicated that vitamin A is a key modulator of the
14), iron deficiency, fluoride defi- immune system. Thus, apart from other benefits, sufficient vitamin A stores
ciency, and vitamin B12 deficiency. could significantly reduce the risk of transmission of HIV from infected moth-
Diseases of affluence are in- ers to their babies.
creasing in the industrial world and
in affluent groups in developing coun-
tries. There is population-based and
epidemiological evidence identifying cular disease, reduced consumption
specific dietary components that can lower the incidence of disease.
early-on increase the probability of The result of scientific research con-
occurrence of adult disease. In the tinues to support the role of diet in
case of some of these components, the development of those diseases
particularly in relation to cardiovas- most responsible for mortality in the
73
The World Health Report 1998
developed world: cardiovascular dis- birth weight has been recognized as
ease and cancer. Excess intakes of a major public health problem, im-
saturated fats, with high blood cho- provement has been slow since many
lesterol levels, are linked to eventual aspects of health are involved. More
adult coronary heart disease. Risk fac- tangible progress has been made in
tors for cerebrovascular abnormalities eliminating neonatal tetanus through
include high blood pressure, to which maternal immunization and promot-
obesity, alcohol consumption, and ing breast-feeding and baby-friendly
excess salt intake are major contribu- hospitals. WHO has shown that peri-
tors. Obesity is also strongly related natal and neonatal deaths can be re-
to the onset of diabetes. The dynamic duced by using an essential set of in-
relationship between modifications in terventions for the mother during
childrens diets and sequential pregnancy and delivery and for the
changes in their health as adults is newborn child after birth.
beginning to emerge. Mortality can be reduced by a fur-
Perinatal and ther 20-30%, and WHO can achieve
WHOs response this by providing guidance (standards,
norms, training material) in the area
neonatal deaths WHO has participated in the achieve- of newborn health to address other
ment of outstanding improvements in issues such as management of sick
child health during the past 50 years. newborn and care of moderately
can be reduced by By capitalizing on the successes de- preterm/low-birth-weight infants. A
scribed in the previous section, WHO milestone was the WHO/UNICEF
using an essential set can lead the way in giving tomorrows conference on infant and young child
children a better, healthier future. feeding (1979), which stimulated ac-
One target for that future is that tion to promote breast-feeding. Re-
of interventions for by the year 2025 there should be over lated subsequent action included the
5 million fewer deaths among chil- Innocenti declaration on the protec-
dren under 5 than in 1995, with pos- tion, promotion and support of
the mother during sible decreases of between 30% and breast-feeding (1990), and the baby-
60% in perinatal and neonatal deaths. friendly hospital initiative. In 1992,
In terms of interventions, the the World Declaration and Plan of
pregnancy and scale of future successes will depend Action for Nutrition was adopted, in-
largely on wider application of the cluding nine goals for the year 2000
WHO/UNICEF integrated manage- and nine action-oriented strategies
delivery and for the ment of childhood illness, on better for improving nutrition.
detection and management of pneu- WHO initially promoted world-
monia, on improvements in nutrition, wide awareness of protein-energy
newborn child and on the continuation of immuni- malnutrition through publications,
zation programmes. Most of all it will cooperation with countries in national
be shaped by the knowledge and nutrition surveys, training of person-
after birth. experience gained in the last half- nel and research. WHO/FAO expert
century. groups elaborated guidelines for nu-
Historical analysis in developed tritional assessment, nutritional re-
countries covering this century has quirements, the role of nutrition
shown less dramatic reduction in peri- units, and national nutrition policies
natal and neonatal mortality than in and strategies. Applied activities and
postnatal mortality, probably due to surveillance were developed in many
the belief that perinatal and neonatal countries, with significant impact on
problems are not amenable to public local or national nutritional activities
health interventions. Although low and status. Particular emphasis was on
74
Health across the life span
preventing micronutrient deficien- ensure that only auto-destruct sy-
cies, especially of iodine, iron and vi- ringes are used, together with safety
tamin A. Global databases were de- boxes, in mass immunization cam-
veloped on each of these in the 1990s, paigns. The introduction of monitors
and indicators and criteria for moni- on all vials of oral polio vaccine sup-
toring the deficiencies, and pro- plied through UNICEF will be ex-
grammes to combat them, were de- tended to include vaccine procured
fined. directly from international manufac-
By 1997, over 160 countries had turers. When the discard point is
received technical and/or financial reached, the end user knows that he
support from WHO for developing should discard the vial. This indica-
and implementing their national food tor and the revised policy on the use
and nutrition policies and plans. The of open liquid vaccine multidose vi-
WHO global database on national als in subsequent immunization ses-
nutrition policies and programmes sions will help reduce vaccine wast-
provides information on the progress age. It will also help use the vaccine During the past
of countries. The WHO global data- to the full extent of its true stability
base on malnutrition and child growth even in difficult access areas where
covers over 80% of the worlds under- the cold chain is not reliable, thus 50 years, the health
5 children, and the databank on reaching children who otherwise
breast-feeding covers 65 countries would not have benefited from im-
(over 60% of the world population). munization services. More research
of most children
The baby-friendly hospital initiative is needed to develop completely safe
is being implemented in over 170 needle-free injection technologies. and young people
countries and over 10 700 hospitals New jet injectors and the administra-
are now designated baby-friendly. tion of vaccines as solids are two of
Over 140 countries now have national the directions that are currently be- between the ages
breast-feeding committees or equiva- ing investigated and which will need
lent. A multicountry study on child additional funding in the coming
growth is being set up in order to de- years. of 5 and 19
velop a new international growth ref-
erence for infants and young children. Older children
Strategies to prevent malnutrition has improved.
in children in the early 21st century
and adolescents
include supporting countries in elimi- During the past 50 years, the health
nating iodine deficiency and its asso- of most children and young people
ciated brain damage, vitamin A defi- between the ages of 5 and 19 has im-
ciency and its associated blindness proved, at least in some ways. Their
and death, and iron deficiency anae- standard of living is generally higher,
mia with its associated mortality and they are at risk of fewer infectious
morbidity; improving infant and diseases, and they are better edu-
young child feeding through promo- cated.
tion of breast-feeding and proper They are the children and adoles-
timely complementary feeding; and cents who have survived the first five
more effectively addressing the nu- dangerous years of life and are not yet
tritional needs of the ever-growing directly challenged by the health
emergency-affected populations. problems of adulthood. Of all the age
In order to avoid unsafe injections groups, theirs is the healthiest, and it
which can result in the transmission is one during which the foundations
of bloodborne diseases, WHO and can be laid for a long and healthy life.
UNICEF are working together to
75
The World Health Report 1998
76
Health across the life span
5-19-year period is also a time when data in Latin America and the Carib-
health-related knowledge, skills, atti- bean. The range is 9-48% in Asia and
tudes and values can be acquired. It 20-52% in Latin America and the Car-
is a long and unique period of con- ibbean; and the proportion is very
tinuous opportunity for public health high in the United States (73%).
intervention. Adolescents aged 15-19 gave
The 5-19 age group represented birth to 17 million babies in 1997,
almost 30% of the total world popu- and 16 million of these births oc-
lation of 5.8 billion in 1997. By 2025, curred in developing countries in
that proportion is projected to be- Asia, Africa, and Latin America and
come one-quarter of a total popula- the Caribbean. In sub-Saharan
tion of 8 billion. Many of these young- Africa, Latin America and the
sters 25% will be in Africa. It is Caribbean, only modest declines are
expected that around 20% of the to- being reported in age at first birth.
tal population of the Americas, Asia All countries in Asia report a decline.
and Europe will be aged 5-19 in 2020. More than 30% of women aged 20- The percentage of
Only limited data exist on the 24 in Latin America and the Carib-
causes of death for the age group bean and 50-60% of women aged 20-
5-19 by region or for individual coun- 24 in most of sub-Saharan Africa women marrying
tries. The age groups tabulated are have their first birth before age 20.
5-14 and 15-24. For every country Adolescent fertility increases risks
with reliable data, the death rate for for both the mother and the child.
before age 20
young persons aged 5-19 is the low- For the adolescent, pregnancy is as-
est of any age group. While the risk sociated with increased risk of nu- is declining
of death is low, the available data show merous pregnancy-related complica-
that in most countries, many of the tions and higher maternal mortality.
leading causes of death are prevent- Adolescent mothers tend to discon- in most countries.
able, especially deaths related to in- tinue their education and thus re-
tentional and unintentional injury. duce their employment options.
The leading cause of death for 5-14- Their children are more likely to
year-olds varies by country and gender. have a low birth weight, to be pre-
Age at first marriage is one of the mature, injured at birth, or stillborn.
most important factors influencing The mortality rates of infants born
adolescent fertility. Populations to adolescent mothers are higher
with later age at first marriage tend than for those of women who give
to be more urban, have higher levels birth at older ages. If projections
of education for women, and use fam- hold however, by 2025 the adoles-
ily planning more than populations cent fertility rate will have declined
with younger age at first marriage. by about 40% in Africa, and 16% in
The percentage of women marrying Latin America and the Caribbean, al-
before age 20 is declining in most though Africa will continue to have
countries in the world. However, early the largest adolescent fertility rate of
age at first marriage is still common any region (76 per 1000 women).
in sub-Saharan Africa, where over The rate is expected to increase by
40% of women aged 15-19 have been 20% in Europe, and 8% in North
married in many of the countries. The America. Among the 10 largest coun-
proportion of births to adolescent tries, the highest rate will be in
women that are unplanned is over Ethiopia (96 per 1000 women), and
one-third in 11 of 20 countries with the lowest is expected to continue to
reported data in sub-Saharan Africa be in China (6 per 1000 women).
and in 7 of 10 countries with reported The number of births to women aged
77
The World Health Report 1998
15-19 is expected to decrease from in contraceptive use among currently
17 million in 1997 to 16 million in married adolescent women vary by
2025. region. Of 13 countries in sub-Saha-
The rates of completing three ran Africa with available data, eight
years of schooling increased between reported increases in use over time,
1987 and 1993, but some countries and five had decreases. Of 11 coun-
still have close to 50% dropping out tries in Asia, contraceptive use among
sooner. While there are now gener- currently married women aged 15-19
ally higher enrolment rates for young increased over time dramatically in
people, some areas remain where eight, with little change in India,
enrolment has not yet reached 50%. Nepal, and Pakistan. Eleven out of 14
Most countries have similar enrol- countries in Latin America and the
ment rates for boys and girls. Women Caribbean showed an increase in use.
currently aged 15-19 are at least two Sub-Saharan Africa generally had the
to three times more likely than lowest, and Latin America and the
Sexual debut women currently aged 40-44 to have Caribbean the highest levels of use.
at least seven years of education. The As regards the contraceptive
increase in education level was found methods used by adolescents, a re-
is taking place in almost all countries in sub-Saha- cent study in the United States found
ran Africa and in all countries in that young female students (aged
North Africa and the Eastern Medi- around 15) prefer to use condoms.
at younger ages, terranean, in Latin America and the However, as female students become
Caribbean. In the developed coun- older, they are gradually less likely to
despite later tries almost all women aged 15-19 had use condoms and more likely to use
seven or more years of schooling. birth control pills. While overall con-
traceptive use does not change, use
marriages. Unhealthy sexuality of birth control pills more than dou-
bles and condom use declines by over
and its consequences 30%. At the same time, current sexual
Sexual debut is taking place at activity increases from almost one-
younger ages, despite later marriages. quarter around age 15 to almost half
Sexual experience before marriage is around age 18. This appears to sig-
becoming more common, as are its nify a change in priority from protec-
consequences including sexually tion against STDs, including HIV in-
transmitted diseases (STDs) and fection, to protection against un-
pregnancy. Men are more likely to planned pregnancy. Few students
have sexual experience prior to mar- appear to be giving high priority to
riage than women. The age of initia- reducing the risk of both unplanned
tion of sexual activity is less than 18 pregnancy and STD infection by us-
in most countries of sub-Saharan ing more than one effective contra-
Africa and around 20 years in Asia, ceptive method, specifically condoms
Latin America and the Caribbean. In and birth control pills.
the United States, it is 16 years for WHO estimates that one in 20
male students and 17 for female teenagers contracts a sexually trans-
students. mitted disease each year. These in-
Contraceptive use has increased clude HIV/AIDS, gonorrhoea, syphi-
in most countries over the past 20-25 lis, chlamydial infection and herpes.
years, as family planning services have Young people are less likely to seek
become more readily available, but care for STDs, especially while they
has decreased in some others. Trends are asymptomatic, and the conse-
quences of the delay or absence of
78
Health across the life span
care can have permanent health ef- provide critical information about
fects including sterility and death. their risk of acquiring HIV infection.
The prevalence patterns for STDs in
developing countries are up to 100
times those in developed countries for Substance abuse and
syphilis, 10-15 times higher for gon- its consequences
orrhoea, and 3 times higher for
chlamydial infection. Incidence is also Adolescence and young adulthood
higher in developing countries. are the periods most associated with
Among developing countries the rates the onset of illicit drug use world-
in Africa are generally higher than wide. A European study on drug
those of Asia and Latin America. abuse in 13 cities found that by age
Human papilloma virus (HPV) can 18 more than 20% had tried canna-
result in cervical cancer 5-30 years af- bis. Solvent use is reported in higher
ter the initial infection. The risk of proportions among the under-15s. A
getting HPV and cervical cancer in study in the United States found that In 1996,
those who had intercourse around age the period of highest risk for canna-
15 has been shown to be double the bis initiation was generally over by
risk in those who do so after 20. age 20, having peaked at 18. Cocaine 400 000 children
In 1997, 590 000 children under initiation peaks later, between 21 and
15 became infected with HIV, bring- 24. Age patterns in Asia and Latin
ing the total of those aged up to 15 America are slightly different, al-
under 15 became
infected to 1.1 million. One contrib- though inhalant abuse is always con-
uting factor is that 1 million children centrated among the youngest age infected with HIV.
enter the sex trade every year. In most group. In Thailand consumers of sol-
parts of the world, the majority of new vents are generally 15-19 years old.
infections are in young people be- In Pakistan the age of onset of heroin
tween the ages of 15 and 24, some- use is just over 12, but cannabis is
times younger. Girls appear to be es- more widespread among those un-
pecially vulnerable to infection, but der 20. Research suggests that ado-
Uganda has recently shown encour- lescents most prone to drug use are
aging evidence that in some cities in- concerned with personal autonomy,
fection rates have halved among ado- are uninterested in conventional
lescent girls since 1990. Even there, goals and receive less parental sup-
however, rates remain unacceptably port and more support from friends.
high, with up to 1 pregnant teenager Peer use of the substance is a pri-
in 10 testing HIV-positive. That rate mary influence, and early onset of
is six times higher than in boys of the use is associated with more intense
same age. These age and sex patterns and wider use of other drugs later. A
are thought to be related to young Brazilian survey of drug use in high
women having older sexual partners, school students found that violence
and the increased susceptibility of the in the home was the factor most fre-
immature female reproductive tract quently associated with the use of
to infection. Because the median in- drugs. Young people who cannot see
cubation period between infection jobs or a better quality of life in their
with HIV and onset of AIDS is nearly future sometimes use drugs to coun-
10 years, many 20-29-year-olds with teract extreme despair and frustra-
AIDS may have been infected dur- tion. The glamorization of drug use
ing adolescence. Surveillance of se- through association with pop music
lected sexual and injecting-drug-use culture, television and film portray-
behaviours among adolescents can als has been noted in some countries.
79
The World Health Report 1998
The age of initiation to injectables by the age of 19; in some cases the
is falling in certain population sub- majority of smokers had adopted the
groups, such as street children, in- habit by 12 years of age. More boys
cluding those in inner cities of devel- tend to smoke than girls. In North
oped countries. In Pakistan the share America, about 20-30% of young peo-
of those who started using heroin be- ple smoke. Given the health conse-
tween 15 and 20 years of age is re- quences, there is a clear need for
ported to have doubled to 24% of smoking cessation initiatives targeted
those surveyed. In the Czech Repub- towards young people.
lic 37% of new problem users are
aged between 15 and 19, as are 50% Depression and suicide
of drug addicts in Bratislava, Slovakia.
In Bulgaria the age of initiation has Adolescence is not an easy time psy-
fallen from around 18 in the mid- chosocially, and adjustment indicators
1970s to 15 for heroin and 12 or are important. The Health of Youth
Given the health younger for volatile substances. This study carried out in European coun-
pattern also occurs in the United tries found that depression, or the
Kingdom, where a survey found that percentage of those reporting that
consequences, 50% of 16-year-olds in north-western they felt depressed once a week or
England had tried illicit drugs, and more, was more common in boys than
20% were considered current users. in girls, and varied considerably
there is a clear need In the United States, the average age among countries. The first symptoms
for cannabis initiation is around 14 of mental illness emerge before the
for smoking cessation years, and approximately 2% of high age of 25, for half of those who will
school students have reported that be affected by it. The effects of uni-
they had injected illegal drugs. Male polar depression and bipolar disorder
initiatives targeted students are more likely than female have recently emerged as important,
students to report this behaviour. and can lead to problems in social in-
Excessive alcohol drinking is teraction and to suicide in extreme
towards young likely to lead to traffic accidents, in- cases.
jury-related death and disability, and Deaths from suicide are
over time, serious degenerative dis- underreported because of a tendency
people. ease of the liver. At least half of those to group them as accidental deaths or
who report drinking started before deaths from undetermined causes.
the age of 15, and a large portion of Currently information is collected on
these started earlier than 12. In stud- suicides and parasuicidal acts (delib-
ies of high school students in Ghana, erate acts with non-fatal outcomes
Kenya and Zambia, prevalence of that attempt to cause or actually cause
drinking was 70-80%. A study of high self-harm). In 10 community survey
school students in the United States studies on adolescents published
showed that during 1990-1995 the since 1986, the yearly prevalence of
proportion who had drunk alcohol on parasuicidal acts varied between over
one or more of the past 30 days, de- 2% and 20%. The differences in rates
clined from 59% to 52%, while the are due to different definitions and
proportion who had five or more measurement issues. The prevalence
drinks of alcohol on at least one occa- of parasuicide is estimated to be 10-
sion on one or more of the 30 days 20 times higher than that of com-
preceding the survey declined from pleted suicides. Three times more
37% to 33% during the same period. women than men attempt suicide,
Various studies report that the while three times more men than
majority of smokers began smoking women succeed.
80
Health across the life span
81
The World Health Report 1998
include vitamin A, iron, iodine and to decreased immunity, increased
folate supplementation or fortifica- drug resistance, or the use of coun-
tion, delaying childbearing, and en- terfeit drugs. Malaria is particularly
hancing early childhood growth (6-18 destructive for young pregnant
months). women as it exacerbates anaemia.
Eating disorders such as ano- Schistosomiasis is the second
rexia nervosa, bulimia and overeating most prevalent tropical parasitic dis-
are more common in the developed ease after malaria. As transmission
countries, as are inactivity and a sed- occurs through contact with water
entary lifestyle. In developing coun- contaminated by infected snails,
tries, the problems are mainly those prevalence is highest in young peo-
of obtaining the right nutrients for ple because of the contact they have
optimal growth, while daily life tends with water sources: women fetching
to include more physical activity. water and men swimming. In some
The extent to which young peo- African countries schistosomiasis is so
Tuberculosis ple are involved in physical activity is common in young men that it is con-
a growing concern in developed coun- sidered to be a sign of passage into
tries. Obesity is increasing, especially adolescence. In young women, as well
has re-emerged in the younger age group. Nutritional as causing anaemia it can result in
problems, especially overconsump- social stigma which reduces chances
tion of fats or sugars, are taking their of marriage. Detection is essential,
as a major disease toll. The Health of Youth study found since a single-dose treatment exists.
that an average of 74% of 15-year-old Tuberculosis has re-emerged as
in young people in boys exercised to the point of being a major disease in young people in
out of breath and sweating more than developing countries. If untreated, it
twice a week outside school. Only can be fatal, and it tends to be more
developing countries. 52% of girls exercised twice a week, aggressive in this age group, leading
and between the ages of 11 and 15, from infection to development of the
girls became less active. disease sooner. For example, the in-
cidence of tuberculosis among 15-24-
Diseases of concern year-olds in the United Republic of
Tanzania is 14% of the total number
for young people
of new cases, and 11% of tuberculo-
Intestinal parasites are endemic in sis-related deaths occur in this age
many developing areas. Treatment of group.
helminth infection (trichuriasis, as-
cariasis) improves school performance. Vaccine-preventable diseases
The prevalence of hookworm infection
peaks around the age of 15. Because As a result of immunization pro-
of the potential blood loss it causes, it grammes, about 8 out of 10 school-
can exacerbate anaemia in those whose age children and adolescents world-
diet contains inadequate iron. wide have been immunized against six
While deaths from malaria tend major infectious diseases of child-
to occur before the age of 5, the dis- hood. Immunization schedules for
ease takes its toll on the young work- basic vaccines vary among different
ing population because of its recur- countries. Many boosters are recom-
rent nature, and contributes to ab- mended during the school-age pe-
sence from work and school. Cerebral riod. For example, boosters for BCG
malaria is becoming more and more have been suggested in many coun-
common in adolescents, perhaps due tries at ages 5-7 and 11-14. A tetanus
booster is recommended during ado-
82
Health across the life span
lescence, especially for pregnant In the past decade an estimated 2
women, and oral polio is also usually million children and young people
given once during school age. Recent have been killed in armed conflict,
studies on immunization in adoles- and three times that number have
cents have focused on mass cam- been seriously injured or perma-
paigns that target this age group, es- nently disabled. By the year 2000, at
pecially concerning hepatitis B. least 120 million young people could
be vulnerable to the indirect effects
Young people at special risk of armed conflict. More than half of
this estimate is made up by the risk
The International Labour Organiza- in Africa and South-East Asia.
tion estimates the number of work-
ing children aged between 5 and 14 WHOs response
at 120 million. The majority of these
children are in developing countries Regrettably, there are few data in
(61% in Asia, 32% in Africa, 7% in most regions of the world on the In the past decade
Latin America). In many of these health status of young people from
countries, children are traditionally the age of 5 to 19 years, on age-
incorporated into the work of their specific mortality and the leading an estimated
families as soon as they are capable, causes of death, and on the underly-
mostly on farms. ing determinants. The available data
However, many millions of chil- are insufficient to assess fully the
2 million children
dren are forced to seek employment trends in this age group, but the pre-
outside the family. Studies indicate ceding section highlights some areas and young people
that in about 20% of cases, the childs that are priorities for WHO and for
income may be essential to an impov- the response of the international com-
erished familys survival. The United munity. Approaches traditionally used have been killed
Nations Economic Commission for to prevent health problems and re-
Latin America and the Caribbean has spond to them when they arise in
reported that without the income of adults, are not always effective in in armed conflict.
working adolescents aged 13-17 younger people.
years, the incidence of poverty in that For the past 30 years, WHO has
region would rise by 10-20%. Thus, been striving to bring adolescent
many children can be found in haz- health and development to the fore-
ardous industries, working long hours front in international public health.
without rest, in conditions that are The main objective has been to ex-
physically or mentally dangerous. pand the knowledge base for adoles-
They are at risk of occupational death cent health and development, to un-
or injury due to poor or non-existent derstand the meaning, parameters
safety standards, inattention, fatigue, and status of adolescent physical, psy-
poor judgement and inexperience in chological and social health, and to
workplaces that have been designed elucidate the specific actions that will
for adults. promote the health and development
In developing countries, exposure of young people in all societies. The
to chemicals, especially pesticides, main results so far have been the dis-
kills more rural children than the semination of vital information, and
most common childhood diseases publicizing priority needs.
combined. Research shows that work- In 1989, WHO was instrumental
ing children are six times more likely in bringing together the health and
to be admitted to hospital than non- youth sectors in countries from all
working children. regions. Since then, a number of
83
The World Health Report 1998
databases on major health issues in support new programming initiatives
young people have been established, in countries are insufficient.
including on reproductive health. Questions from countries abound
Considerable effort has been invested related to statistics and research find-
in expanding the knowledge base for ings needed to make the case for pro-
adolescent health and development. gramme activities and seeking exam-
For example, a WHO technical report ples from other countries demonstrat-
resulted from a WHO/UNFPA/ ing promising approaches to inspire
UNICEF study group which met in new ideas and confirm current direc-
1995 to review the evidence of key tions. These demands cannot always
interventions used in programming be met because sound programme
for adolescent health. It described the support materials and resource peo-
current extent of experience in coun- ple are not readily available.
tries, and highlighted the essential The increased attention to adoles-
factors and strategies needed to es- cent health has resulted in a burgeon-
The full range tablish, implement and sustain ado- ing of projects in developing coun-
lescent health programmes. The re- tries, often focused on single health
port aims to provide substantive guid- issues. When resources are limited,
of interventions ance and reference material useful for efforts focusing on what is perceived
programme development in coun- as the single most important health
tries. problem affecting adolescents in the
for adolescent health In parallel with this and in order area, may seem to be meeting the
to bridge the gap between advocacy most pressing need. However, there
is not yet developed. and action, WHO has developed a are good technical as well as practi-
series of methods specially adapted cal reasons to deal with several related
for use in the area of adolescent health issues in an integrated manner.
health. All are based upon the cen- The need to modify approaches to
tral principle of eliciting knowledge meet the special needs of adolescents
directly from young people and adults is further illustrated by problems as-
on their expressed needs and on so- sociated with the diagnosis and treat-
lutions to their problems which will ment of tuberculosis. WHO is
work. strongly advocating the expanded use
The full range of interventions for of daily observed treatment of short-
adolescent health is not yet devel- course chemotherapy regimens
oped. In recent years, emphasis has (DOTS), as a means to ensure that
been placed on supporting efforts that individuals diagnosed with the disease
enable adolescents to build life skills. complete their treatment. Unfortu-
Counselling has been accepted as an nately, adolescents are generally con-
important intervention, but the pro- sidered to comply poorly with thera-
vision of health services to adolescents peutic regimens due to factors such
has received scant attention. Capac- as increased autonomy from family
ity for monitoring progress at the pro- and limited resources available to
gramme implementation level is lim- them. The challenge facing individual
ited. Weaknesses are difficult to docu- clinicians and national tuberculosis
ment, and available information is not programmes alike is to determine
systematically used or valued. Fre- how best to improve compliance, and
quently the measures of impact, such to ensure that adolescent patients do
as reducing adolescent pregnancy or in fact take the medications that they
substance use, cannot be firmly es- need.
tablished as an outcome of a single WHO has helped Member States
intervention. Technical resources to to develop and test a range of epide-
84
Health across the life span
miological and qualitative guidelines
and methodologies to assess the ex-
tent and nature of psychoactive sub-
Box 15. School health guidelines
stance use, and to develop effective
interventions. A consolidated epide- The Division of Adolescent and School Health of the United States Centers
miological manual has been prepared for Disease Control and Prevention, has developed three sets of guidelines
so that Member States can develop that identify the most effective policies and programmes that schools can
standardized instruments and meth- implement in order to promote healthy choices related to tobacco, nutrition,
odologies for data collection, analysis and physical activity: Guidelines for school health programmes to prevent
and dissemination. tobacco use and addiction (published in 1994), Guidelines for school health
WHO has already published a first programmes to promote lifelong healthy eating , and Guidelines for school
global status report on tobacco or and community health programmes to promote physical activity (1996). These
health and provides continuous sup- guidelines were developed through exhaustive reviews of published research
port to Member States in strength- and exemplary practice, as well as collaboration with academic experts and
ening national tobacco control. A first over 50 national, federal, and voluntary organizations involved in child and
draft of the global report on alcohol adolescent health.
and public health was prepared in The guidelines include specific recommendations to help states, dis-
1997, and work has started on an in- tricts, and schools implement health promotion programmes and policies
ternational framework convention on that have been found to be most effective in promoting healthy eating and
tobacco control. The finalization of physical activity patterns, and preventing tobacco use, among youth. Rec-
the international framework conven- ommendations cover topics such as policy development, curriculum selec-
tion on tobacco control in the year tion, instructional strategies, staff training, family and community involve-
2000 is expected to establish effective ment, and programme evaluation. The guidelines also cover the scientific
mechanisms for the implementation rationale for school-based chronic disease prevention programmes, as well
of national and international tobacco as how and why these programmes should be delivered within the framework
control. of a comprehensive school health programme.
Target audiences for the guidelines include parents, classroom and physical
education teachers, coaches, food service staff, substance abuse prevention
Health education
staff, school administrators and board members, curriculum developers,
The key to promoting health in chil- textbook publishers, staff development specialists, staff of teacher training
dren of school age and adolescents is institutions, public health and social services professionals, and community-
education. The best opportunities for based sport and recreation professionals.
positively influencing the health of For further information on School Guidelines contact: DASH Inquires, Division of Adolescent and
this age group are found in the school School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for
(Box 15). A WHO Expert Commit- Disease Control and Prevention, Mail Stop K-32, 4770 Buford Highway, NE, Atlanta, Georgia, USA,
or electronic mail at www.cdc.gov/nccdphp/dash.
tee on Comprehensive School Health
Education and Promotion noted in
1995 that promoting health through
schools could simultaneously reduce eases; protect from discrimination,
common health problems; increase harassment, abuse and violence; and
the efficiency of the education sys- reject the use of tobacco, alcohol and
tem; and thus advance public health, illicit drugs.
education, social and economic devel- Secondly, every school must en-
opment. As a result of the Commit- able children and adolescents at all
tees work, the WHO Global School levels to learn vital skills. Health edu-
Health Initiative made 10 recommen- cation should include topics such as
dations, of which three are most likely infectious diseases, nutrition, preven-
to have a direct effect on health. tive health care and reproductive
Firstly, the school environment health and should enable young peo-
must provide safe water and sanitary ple to protect the well-being of the
facilities; protect from infectious dis- families for which they will eventu-
85
The World Health Report 1998
ally become responsible and the com- malnutrition, anaemia and helminth
munities in which they reside. Life infection in children, fortification of
skills education should help them foods with iron and micronutrients
make healthy choices and adopt and anti-helminth treatment should
healthy behaviour throughout their be a priority.
lives. The health of 5-19-year-olds can
Thirdly, every school should pre- be protected by restricting their ac-
vent when possible, treat when effec- cess to tobacco, especially cigarettes.
tive, and refer when necessary, com- Legislation should be passed to ban
mon health problems. Schools should the sale of tobacco products to chil-
provide safe and nutritious food and dren, and school-based training pro-
micronutrients to combat hunger, grammes on the prevention of to-
prevent disease, and foster growth bacco use should be more widely in-
and development. They should estab- troduced. The most successful anti-
lish prevention programmes to re- smoking programmes are those which
Education is the duce the use of tobacco, alcohol and are oriented to the developmental
illicit drugs, and behaviour that pro- needs of adolescents, emphasizing
motes the spread of HIV infection. the physical and social consequences
foundation for They should when possible identify of smoking and preparing adolescents
and treat infections, and oral, vision to resist the social pressure they face
and hearing problems and psycho- from their peers and others.
the future success logical problems, and refer those af- Fostering respect between young
fected for appropriate treatment. men and women is another priority,
of the young. Education is the foundation for essential in shaping the lives of the
the future success of the young, as young and developing strong family
without basic literacy and numeracy units. Family structure is central to
the potential for individual develop- their present and future health, and
ment is drastically reduced. As the family communication is a determi-
5-19 population increases in develop- nant of healthy choices. It is particu-
ing countries over the next 20-30 larly important to increase knowledge
years, continuing efforts will be among adolescents about the value of
needed to increase enrolment in edu- condoms in giving dual protection
cation. The potential for distinction, from unplanned pregnancies and
necessary in defining a young person from sexually transmitted diseases,
as autonomous, can come either including HIV. These educational ef-
through excellence in school, sports forts must be made well before they
and other activities, or through un- reach the age of 15.
healthy risk behaviours. Those deriv-
ing self-esteem from the positive ac- Adults
tivities are less likely to seek status
through smoking, drinking and drugs.
The expansion of the adult popula-
Delaying the initiation of drink-
tion is one of the most important of
ing alcohol, smoking and pregnancy
the demographic changes now occur-
at least until closer to the end of the
ring. Those aged between 20 and 64
teenage years should be encouraged
years represent just over half of all the
through education, parental guid-
people in the world, and are expected
ance, health promotion and legisla-
to account for 58% by 2025. At the
tion. More physical exercise and im-
same time, the proportion of older
proved nutrition should also be pro-
people needing support from work-
moted in this age group. In areas
ing-age adults is forecast to increase
where there are high prevalences of
86
Health across the life span
from about 12% in 1995 to about 17% diabetes for which there are well-
in 2025. known risk factors. The most impor-
The young and old of all societies tant are tobacco smoking and un-
look to adults to provide and care for healthy diet. Obesity is becoming one
them. In their working years, adults of the most important contributors to
produce and deliver almost all the ill-health. Heavy alcohol consumption
essential goods and services that the increases the risk of developing some
world consumes. By working, adults cancers and mental disorders, injuries
earn the means to support their chil- and cirrhosis of the liver.
dren and their aged relatives. The Among communicable diseases,
better the health of the adult popula- tuberculosis, HIV/AIDS, and acute
tion, the greater is its ability to play lower respiratory infections are the
this vital role, and the better is the leading killers.
health of society as a whole. All of these diseases, infectious and
This is particularly true of women, noninfectious, are also major causes of
whose health critically affects that of illness and disability. Most of the esti- In 1997,
their children and of future genera- mated 1 million yearly deaths due to
tions. Womens health receives spe- external causes (such as suicide or oc-
cial attention in both this section and cupational injuries) involve adults. there were about
the following section on the health of Pregnancy-related causes kill 585 000
older people. women a year. Huge numbers of
Adults aged 20-64 are the chief women suffer from domestic and
15.4 million deaths
beneficiaries of the improvements in other forms of violence ranging from
life expectancy that have occurred in rape to genital mutilation. among those
the past 50 years. Between 1955 and
1995, death rates among them de- Circulatory diseases
clined by 50%. Most people who have aged 20-64.
reached the age of 20 have a very Diseases of the heart and circulation
good chance of surviving beyond the cardiovascular and cerebrovascular
age of 65. In 1955, only 61% of 20- are for most adults the biggest risks
year-olds could expect to reach 65; in to life. They account for at least
1995 78% could, and by 2025, 85% 15 million deaths, or around 30% of
will. the annual total, every year. Many
who die of circulatory diseases are
Leading causes of death under the age of 65. Many millions
more are disabled by them.
However, this optimistic picture Circulatory diseases are responsi-
should not obscure the fact that in ble for more than 5 out of 12 million
1997, there were about 15.4 million deaths in developed countries, and
deaths among those aged 20-64. All of are rapidly emerging as a major pub-
these deaths can be described as pre- lic health concern in most develop-
mature. Apart from the human losses ing countries. They already account
to families and dependants, they also for 10 million out of 40 million deaths
constitute a huge loss of economic pro- in the developing world. The most
ductivity. The majority of them are important circulatory diseases are
preventable. For societys well-being, high blood pressure (hypertension),
prevention must be the priority. coronary heart disease and
Most of these deaths are due to cerebrovascular disease. Worldwide,
chronic noncommunicable diseases there are more deaths from coronary
circulatory diseases, cancers, chronic heart disease (7.2 million) than stroke
obstructive pulmonary disease, and (4.6 million).
87
The World Health Report 1998
causes 17% of all cardiovascular
Box 16. Stroke - Destiny or challenge? deaths, mostly in people over 65, and
accounts for 23% of all cardiovascu-
Over the past 35-40 years a decline in stroke mortality has been observed in lar morbidity in people under 45.
25 countries, most substantially in Japan, North America, and western Eu- Another important risk factor, high
rope, with an acceleration in this decline in the mid-1970s. In contrast, blood cholesterol levels, can be re-
stroke mortality has increased in eastern European countries. There is evi- duced by modifying the diet or by
dence that stroke is increasing in many developing countries, especially in medicaments.
those where hypertension has become a major public health problem. Among circulatory diseases,
Although the reasons for the recent decline in stroke mortality are not stroke and other cerebrovascular
fully understood, there is some evidence that both improvements in case- diseases are the second most com-
fatality rates (survival after stroke) and in attack rates (the occurrence of mon cause of death, accounting for
the event itself) have caused the improvements in stroke mortality. The lim- more than 4.6 million deaths world-
ited available evidence suggests that a decline in case-fatality may be related wide. Morbidity and mortality occur
to decreased severity of the disease, with the acute event becoming more mainly in the over-65 age group. High
mild. Improved management in the acute phase may also have contributed. blood pressure, affecting about 20%
Declining stroke rates have been attributed in part to improved hypertension of the adult population, both in the
control, and increasing stroke incidence has conversely been considered a developed and developing world, is
likely effect of deteriorating lifestyle factors in the population. the most important risk factor for
The widespread belief that the total burden of stroke is diminishing is stroke (Box 16). Even modest blood
mistaken however, because the total number of persons in the older popula- pressure reduction in hypertensive
tion is increasing as is the proportion of people surviving an acute stroke people could prevent half of the stroke
with disabilities. Stroke will present a formidable humanitarian and economic events worldwide. Other major risk
problem if effective prevention and control measures are not implemented. factors mentioned above in the con-
Control of hypertension and smoking cessation are most important for text of coronary heart disease are
stroke prevention. Even modest blood pressure reduction in hypertensive equally important for cerebrovascular
people could reduce stroke events worldwide by half. Further efforts to im- disease, in particular smoking. Alcohol
prove hypertension control are warranted in almost all populations. This re- consumption also increases the risk.
quires both more effective drug treatment and non-pharmacological meas-
ures to prevent and control high blood pressure. Cancer
Cancer of the lung was the highest-
ranking cancer in 1997, both for the
In many industrialized countries total population and for the popula-
coronary heart disease death rates tion aged 15 to 64. The most signifi-
peaked in the 1960s and early 1970s cant global trends in cancer mortal-
and have since declined dramatically. ity are listed below. Certain cancers
In Australia, New Zealand and the are dealt with at greater length in the
United States, for example, deaths womens part of this section and its
from coronary heart disease have counterpart in the section on older
fallen by more than 50% since the people. Fig. 10 shows the burden of
mid-1960s. But this condition is now cancer in 1997.
becoming more frequent in develop- Long-term trends in survival are
ing countries as their populations age available only for the United States
and adopt unhealthy habits and be- and some European countries, which
haviours. The major risk factors are are experiencing an overall improve-
high blood pressure, cigarette smok- ment that is more marked in males.
ing, unhealthy diet, lack of physical In 1990, the prognosis for cancer at a
activity and diabetes. given stage was similar in all affluent
Cigarette smoking is the most countries. A study of survival in some
readily preventable risk factor. It developing countries has shown sig-
88
Health across the life span
Prevalence, worldwide
Males Females
3135 Lung 1335
2315 Stomach 1400
3175 Colon-rectum 3010
765 Liver 650
Breast (female) 7995
615 Oesophagus 520
2005 Mouth-pharynx 805
3505 Prostate
1460 Lymphoma and myeloma 1280
685 Leukaemia 880
Cervix 3955
1850 Bladder 485
Ovary 1655
725 Kidney 535
Corpus uteri 1425
530 Melanoma of skin 385
89
The World Health Report 1998
nificantly lower survival for those tu- of mortality rates in the near future.
mours which are curable but require Incidence of prostate cancer in-
expensive drugs or technology cou- creased dramatically in developed
pled with specific expertise. Examples countries after a cheap screening test
are lymphomas, leukaemias and can- (prostate-specific antigens) became
cer of the testes; also, breast cancer available. However, mortality is in-
mortality is more elevated than would creasing rather slowly, suggesting
be predicted from incidence. Poor over-diagnosis and little improvement
prognosis indicates lack of appropri- of prognosis. In the European Union,
ate treatment. mortality is expected to increase by
In men, the effect of smoking still some 25% between 1990 and 2010.
determines the high risk of dying Incidence of lymphoma is in-
from lung cancer in developed coun- creasing in all developed countries.
tries. However, incidence and mortal- Due to improved survival, mortality
ity are declining among the young is rising more slowly.
Respiratory diseases generations in rich countries, with In spite of increasing incidence of
very few exceptions (such as France, testicular cancer, mortality is declin-
Japan and Spain). Mortality is falling ing, due to substantial improvement
are second only in men in the United States, and be- in treatment and survival.
gan to fall in the European Union in
to cancers as causes 1985. On the other hand, a continu- Respiratory diseases
ing rise is foreseen in Asia and Latin
America. In women, mortality is on Respiratory diseases are second only
of death and the rise in almost all developed coun- to cancers as causes of death and dis-
tries, with the exception of Ireland ability in adults, and rank among the
and the United Kingdom. three principal causes of lost work-
disability in adults. Mortality from stomach cancer days worldwide. Chronic obstructive
has declined and it no longer ranks pulmonary disease a grouping of
first among world cancer deaths. chronic bronchitis and emphysema,
Incidence of breast cancer is in- for which cigarette smoking is the
creasing in the intermediate or low- most important risk factor kills
risk populations (Asia, eastern and 2.9 million adults a year. At least 15%
southern Europe and Latin America). of middle-aged smokers in devel-
In high-risk countries such as those oped countries have abnormal lung
in northern and north-western Eu- function.
rope, Australia, New Zealand and Asthma is a major chronic airway
North America, there was a real in- disorder affecting 155 million people
crease until the late 1980s, after which of all ages worldwide. Asthma often
the introduction of breast screening appears very early in childhood and
has modified the picture. if it is inadequately treated, the life-
The incidence of colorectal can- long consequences can be substantial
cer increases along with economic and disabling. The major burden of
development. In rich countries, early asthma falls on the developing world.
diagnosis and improved survival keep Increasing prevalence is associated
mortality in control. However, screen- with spreading urbanization, expo-
ing will not be widely available in sure to domestic mites, vehicle ex-
many countries currently at interme- hausts and passive smoking.
diate risk (in eastern Europe and
Latin America) where the incidence
is on the rise. It is possible, therefore,
to predict a general parallel increase
90
Health across the life span
91
The World Health Report 1998
92
Health across the life span
Map 8. AIDS deaths and HIV/AIDS prevalence among adults aged 15-49, by WHO region,
1997yestimates g ,
Europe
AIDS deaths: 15 000
Rate per 100 000 adult population: 3
HIV/AIDS prevalence: 680 000
Rate per 100 000 adult population: 153
93
The World Health Report 1998
Saharan African countries show simi-
Box 17. The evolution of AIDS lar trends.
The potential for continued
Recognized as an emerging disease only in the early 1980s, AIDS has rapidly spread of HIV/AIDS in Asia and the
established itself throughout the world, and is likely to endure and persist well Western Pacific is real and requires
into the 21st century and probably beyond. determined and sustained prevention
AIDS has evolved from a mysterious illness to a global pandemic which has efforts. Several countries have already
infected tens of millions in less than 20 years. It is now prevalent in virtually all experienced intense epidemics in cer-
parts of the world. tain population groups, or in some
There are currently an estimated 30.6 million people living with HIV/AIDS, cases, in the population at large. In
and 5.8 million new infections occurred in 1997. Since the beginning of the these countries, including Cambodia,
epidemic there have been an estimated 11.7 million deaths from AIDS, 2.3 India, Myanmar and Thailand, AIDS
million of them in 1997. The total number of AIDS orphans (HIV-negative children has imposed new demands on health
who lost their mother or parents to AIDS when they were under the age of 15) is care systems.
near 8 million since the beginning of the epidemic. Drug injection is behind the dra-
The AIDS virus affects people who are particularly vulnerable. The main be- matic surge in HIV infection in sev-
havioural characteristics that facilitate the spread of HIV are unprotected sexual eral eastern European countries, ac-
activity with different partners and sharing of equipment by injecting drug users. counting for the majority of the
Women with HIV can also transmit it to their newborn children. 100 000 new infections estimated to
Adolescents and young adults who are becoming sexually active for the first have occurred in 1997. In Ukraine,
time are particularly exposed, and are therefore an important target group for where around 70% of infections have
preventive action. been in drug users over the past three
The AIDS virus is a virtually invisible passenger that uses the human body as years, some 25 000 cases of HIV in-
a vehicle throughout a long incubation period before causing illness more than 10 fection have been reported so far, half
years later in many cases. During part of that time HIV can be transmitted by an of them in 1997. It is possible that a
infected but symptomless individual to other people, who likewise will be its similar pattern will be seen elsewhere
unwitting vehicle for further years and ensure its wider spread. In addition, the in the region.
virus can mutate within an individuals body, so that by the time it is transmitted In Latin America and the Carib-
to someone else, it has changed some of its characteristics. This lack of stabil- bean, AIDS has already overtaken traf-
ity is part of the complex make-up of HIV which will make the development of fic injuries as a cause of death. How-
new drugs - and possibly a vaccine - very difficult. ever, a recent drop in AIDS mortality
From being first regarded as a minority group disease, AIDS has gradually similar to that seen in western Eu-
been shown to be essentially a heterosexually transmitted infection. However, rope and North America has been
the evidence that transmission is most likely to occur with unsafe sexual behav- recorded in Sao Paulo, Brazil, and is
iour has engendered complacency among populations which consider themselves attributed to the increasing use of
outside that danger zone - either socially, behaviourally or geographically. This antiretroviral therapy. In the United
misperception or denial of risk is often a factor for further spread of the virus. States in 1996, AIDS dropped into
In some industrialized countries, AIDS is regarded as a disease restricted to second place among leading causes of
the developing world. Such complacency is one more reason why AIDS will per- death in people aged 25-44 for the first
sist for a very long time. For the history of disease shows that when compla- time since 1992 (injury took over in
cency occurs and vigilance weakens, infectious agents take full advantage of the first place). In western Europe also,
situation. the annual incidence of new cases of
The prospects for HIV/AIDS control depend largely on recognizing the scale AIDS has begun to decline.
of the threat and on political commitment to implementing policies to counter it. Unfortunately, access to anti-
A key aspect of national AIDS programmes is early intervention addressing sex retrovirals in the developing world is
education, condom promotion and STD care; creating an enabling environment often difficult or impossible. It is en-
to facilitate behavioural change; and providing the necessary means to do so. couraging, however, that in some de-
Research is resulting in better understanding and treatment of HIV/AIDS. Com- veloping countries such as Thailand
bined drug therapy has lengthened life for many patients, but is inequitably dis- and Uganda, the effects of preventive
tributed. interventions are beginning to be
seen. As a result of the increase in
94
Health across the life span
condom use and declines in other causes the loss of between 1 and 14
sexually transmitted diseases, the days of work. Increasing numbers of
number of people expected to be- cases are reported among interna-
come HIV-positive in Thailand is now tional tourists and business travellers,
less than previously projected. Popu- of whom some 30 million from non-
lation growth is now expected to re- endemic countries visit malaria-
main positive, whereas in 1994, popu- endemic countries each year.
lation projections for Thailand indi- Resistance to the antimalarial
cated negative population growth by chloroquine was reported on the
2010. It appears likely, nevertheless, Thai-Cambodia border and in
that many if not most of the 30 mil- Colombia in 1961, and spread in the
lion people currently infected may late 1970s to Africa, where it has been
well die perhaps within the next reported from practically all endemic
decade. African countries. Chloroquine is still
Each year, there are 300-500 mil- clinically effective in most primary
lion clinical cases of malaria and 1.5- health care settings, but its loss of ef- Without preventive
2.7 million people die of the disease. ficacy in some areas has been accom-
Of these deaths, 90% occur in sub- panied by an increase in malaria mor-
Saharan Africa, mainly in children un- bidity and mortality. action, the burden
der 5. The adult victims of malaria are
those who were not previously ex- Occupational diseases of occupational
posed and thus have no immunity.
Young men and women bear only 5-
and injuries
7% of the malaria burden. For many WHO estimates that every year there diseases and injuries
it is virtually an occupational disease are 217 million cases of occupational
because of their work in land devel- disease and 250 million cases of inju-
opment, mining, construction and ries at work, including 330 000 fatal will escalate.
seasonal migratory agriculture in cases. There are about 50 million new
malarious regions. cases per year of occupational respi-
Apart from being a disabling and ratory diseases. The 10 major work-
sometimes fatal disease in itself, ma- related illnesses are respiratory dis-
laria in non-immune pregnant eases, musculoskeletal disorders, can-
women, or previously immune cer, injuries, cardiovascular diseases,
women in their first pregnancy, causes reproductive disorders, neurotoxic
spontaneous abortion in up to 60% disorders, noise-induced hearing loss,
of cases and a maternal mortality rate dermatological disorders and psycho-
of up to 10%. Malaria in adults also logical disorders.
has a serious economic impact in Without preventive action, the
terms of both lost productivity and burden of occupational diseases and
treatment costs. Direct losses due to injuries will escalate. By the year
the disease in Africa in 1989 were cal- 2000, the global labour force will
culated to be $ 800 million; by 1997 grow to some 3 billion people. Par-
the figure had risen to $ 2.2 billion. ticipation of women in the workforce
This is largely due to the rising costs will increase. Many workers will be
of treatment resulting from antima- exposed to occupational hazards
larial drug resistance. Treatment costs such as toxic chemicals and dusts, al-
for a normal bout of malaria can be lergenic agents and carcinogenic
as low as $ 0.15; to treat resistant agents, and to serious injuries caus-
strains can cost $ 7 per patient. In the ing more than one months absence
malaria-endemic countries of South from work.
America, an episode of the disease
95
The World Health Report 1998
96
Health across the life span
trained health workers, breast self- correct treatment, or to a chain of
examination, and mammography. Tri- events resulting from any one of the
als have shown that through screen- above (Fig. 11). The single most com-
ing mammography followed by ef- mon cause accounting for a quarter
fective treatment breast cancer of all maternal deaths is obstetric
mortality can be reduced by 30% in haemorrhage, generally occurring
women aged 50 years and above. postpartum, which can lead to death
There is as yet no clear evidence of very rapidly in the absence of prompt
benefit from screening programmes life-saving care, including drug treat-
for premenopausal women. The or- ment to control bleeding and, where
ganization and implementation of needed, blood transfusions.
mass screening programmes are far Puerperal infections, often the
beyond the resources of developing consequence of poor hygiene during
countries, and breast self-examination delivery, or untreated reproductive
remains the main option.
Cervical cancer is a preventable
major cause of death, with 425 000 Fig. 11. Causes of maternal deaths, latest available year
LYT 980
new cases are diagnosed each year, Severe bleeding
mostly in developing countries. The
disease is one of the few cancers with
25%
a readily detectable and treatable pre-
cursor stage. In developing countries,
screening is rarely accessible to a
Indirect causes 20% 15% Infection
women in rural areas, or to ageing
women, who are at greatest risk.
Screening once every five years and 8% 12%
appropriate treatment can result in a
reduction of 85% in mortality; screen- 13% 8%
b
ing once every 10 years could result Other direct causes Eclampsia
in a 64% reduction. Screening older
women, even once in their lifetime,
will prevent more cases of cervical Unsafe abortion Obstructed labour
cancer than screening a small propor- a
Indirect causes including, for example: anaemia, malaria, heart disease.
tion of younger women every few b
Other direct causes including, for example: ectopic pregnancy, embolism, anaesthesia-related.
years.
Around 585 000 women die each
year of pregnancy-related causes, tract infections (including those that
99% of them in developing countries. are sexually transmitted) account for
These are among the leading causes some 15% of maternal mortality. Such
of death for women of reproductive infections can be easily prevented.
age in many parts of the world. Where Hypertensive disorders of pregnancy,
women have many pregnancies, the particularly eclampsia (convulsions),
risk of related death over the course result in some 13% of all maternal
of a lifetime is compounded. In deaths; they can be prevented
Africa, the risk is around 1 in 16, com- through careful monitoring during
pared with 1 in 65 in Asia and 1 in pregnancy and treatment with rela-
1400 in Europe. About 80% of ma- tively simple anticonvulsant drugs in
ternal deaths are due to direct causes, cases of eclampsia. Around 7% of
that is, obstetric complications of maternal deaths occur as a result of
pregnancy, labour and the puerper- prolonged or obstructed labour.
ium, to interventions, omissions, in- Other direct causes include ectopic
97
The World Health Report 1998
of the most significant is anaemia,
Box 19. Family planning which can cause death through cardiac
arrest and is also an underlying cause
In the 1960s there was growing concern among countries about the nega- in a substantial proportion of deaths.
tive impact of uncontrolled population growth on economic and social devel- Other important indirect causes of
opment, especially in developing countries. Human reproduction and espe- death include hepatitis, cardiovascu-
cially contraception and family planning, previously taboo subjects at the lar diseases, diseases of the endocrine
World Health Assembly, were now openly discussed. In 1965, the Health or metabolic system, and diseases of
Assembly adopted a resolution directing WHO to conduct research on medi- the central nervous system.
cal aspects of sterility and fertility control methods and health aspects of The percentage of contraceptive
population dynamics. A unit for this purpose was set up in mid-1965 at users has increased from around 14%
WHO headquarters. It subsequently became the Special Programme on Re- in 1960-1965 to an estimated 60% of
search, Development and Research Training in Human Reproduction. women of reproductive age in 1994
Meanwhile, other organizations within the United Nations system and (Box 19). Women are using family
among the large foundations had become increasingly active in the area of planning in increasing numbers in
population and family planning. Important new organizations were created every region of the world. In devel-
during this period, such as the International Planned Parenthood Federation oping countries, five times as many
(1952), the Population Council (1952), and the Population Trust Fund UN couples are now using contraception
(now the United Nations Population Fund). as in the 1960s. Worldwide, however,
Three large intergovernmental conferences on population held in Bucha- the full range of modern methods is
rest (1974), Mexico City (1984) and Cairo (1994) brought together repre- unavailable to up to 350 million cou-
sentatives of governments, specialized agencies, organizations of the United ples.
Nations system, intergovernmental organizations, nongovernmental organi- Present in most societies, but un-
zations and the media to discuss issues of population and development and recognized, unreported or tacitly ac-
formulate plans of action. All these meetings endorsed population and family cepted, violence against women is a
planning as integral to overall development. They established linkages with major health issue. Reliable informa-
parallel concerns being discussed in other forums, such as health, the envi- tion about its extent is unfortunately
ronment, children, women and human rights. scant. Between 16% and 52% of
Population policies to provide the policy and legislative framework for the women in some parts of the world
provision of family planning are essential. The successive population confer- suffer physical violence from their
ences and other important meetings have encouraged the development and male partners. At least one in five
adoption of such policies, and by 1991 (the latest dates for which figures are women suffer rape or attempted rape
available) 96% of governments had policies directly supportive of the provi- in their lifetimes. Rape and sexual
sion of family planning care, compared with 55% in 1974. torture are systematically used as
Fertility regulating methods that are safe, effective, reversible, easy to use weapons of war. Psychological
and affordable are also essential. Research on technology development and trauma, sexually transmitted diseases,
assessment by WHO and others in collaboration with industry, government unwanted pregnancies and reproduc-
research councils and institutions throughout the developed and developing tive health problems are among the
world have contributed substantially towards making such methods available. consequences. Female genital muti-
lation is a traditional cultural practice,
but also a form of violence against the
pregnancies, embolisms and deaths girl child which affects her life as an
related to interventions such as an- adult woman. The number of girls
aesthesia. and women who have been subjected
Around 20% of maternal deaths to this practice is estimated at more
are due to indirect causes, that is, the than 130 million worldwide.
result of pre-existing disease or disease
that developed during pregnancy, WHOs response
which was not due to direct obstetric
causes but was aggravated by the By the late 1980s and early 1990s
physiological effects of pregnancy. One it was clear that, with increasing
98
Health across the life span
co-infections with HIV and the zation has helped Member States to
spread of multidrug-resistant strains, establish or strengthen their national
the tuberculosis epidemic was wors- AIDS programmes; to carry out rapid
ening. In 1991, the World Healt As- assessment; to improve diagnostic,
sembly called for the strengthening laboratory and blood screening capac-
of district-centred tuberculosis pro- ity; and to plan national activities and
grammes and the widespread imple- long-term responses based on reliable
mentation of directly observed, stand- projections. A report on the implica-
ardized, short-course chemotherapy tions of the new antiretroviral treat-
(DOTS) and in 1993, WHO declared ments was published in 1997.
a global tuberculosis emergency. The development of a cheap, safe
The DOTS strategy incorporates and effective vaccine is a priority, al-
components that were discovered, though this is not likely to be achieved
developed or expanded by a number for at least 10 years. Any major initia-
of organizations and individuals over tive in this area requires that the part-
the past 45 years. These components ners play three major roles: support- The development
are being used in one integrated strat- ing and coordinating research; nego-
egy to document and manage the cure tiating with industry to ensure that the
of tuberculosis cases, thus reducing products of research will be available of a cheap, safe
the sources of infection in the com- to those most in need; and seeking
munity. Although there is no doubt mechanisms to encourage vaccine re-
about the effectiveness of DOTS in search, which is commercially far less
and effective vaccine
curing patients, it is still a strategy attractive than research on new drugs.
waiting to be used. Sustained politi- The development of a microbicide is is a priority.
cal commitment is a major determi- equally urgent as the use of such a
nant of success. Governments must product is a method that is simple, can
recognize the long-term benefits of be controlled by women, and could
providing the resources and staff nec- be inexpensive. This highly promis-
essary to ensure the proper imple- ing area, likely to produce the quick-
mentation of DOTS. The benefits to est and widest benefits, needs an ur-
individuals and society as a whole are gent injection of funds and effort.
overwhelming in comparison to the Drug therapy, on the other hand, is
investment involved. Current re- far from being a practical option (on
search and surveillance initiatives are grounds of cost, compliance, efficacy
giving WHO a clearer picture of the and resistance) or widely applicable
threat of multidrug-resistant tubercu- as yet.
losis, as well as providing more accu- The majority of occupational
rate verification of data both of diseases can be prevented through
which help the world respond more action in the work environment, im-
effectively to the epidemic. Because provement of working conditions and
breakthroughs in diagnostic tools, the reduction of harmful exposures.
drugs and vaccines may be years in WHOs work on occupational health
the making, the worlds future success dates back to 1950, when it set up a
in eliminating tuberculosis as a pub- joint committee with ILO. At the be-
lic health threat will rely on the par- ginning of the 1990s, WHO instituted
allel strategies of aggressive expansion a new agenda for work, development
of DOTS and a continued commit- and health, which led to the develop-
ment to research. ment of the Global Strategy for Oc-
In the 1980s, WHO alerted world cupational Health for All. Member
authorities to national epidemics of States are urged to devise national
HIV/AIDS. Since 1986, the Organi- programmes, with special attention to
99
The World Health Report 1998
full occupational health services. and women; violence against women;
WHO promotes health in the and maternal morbidity and mortal-
workplace in a wider sense through ity. Activities at the country and re-
advocating the concept of the healthy gional levels have focused on data
company or healthy organization. collection and research in areas where
In 1997, WHO cosponsored and gaps in knowledge about womens
participated in the international sym- health exist, e.g. to examine the
posium on maritime health in household factors affecting maternal
Norway and the international sympo- morbidity and mortality.
sium on occupational asthma and al-
WHO activities in reproductive
lergy held in the Russian Federation,
health in 1997 included the expansion
as well as the international conference
of the research initiative on the role
on occupational health in the informal
of men in reproductive health; publi-
sector which took place in
cation of data from the WHO collabo-
Indonesia. A joint ILO/WHO initia-
The progressive tive to eliminate silicosis is planned in
rative study of cardiovascular disease
and steroid hormone contraception;
1998. The disease is common in la-
the completion of data collection
bourers in mines, quarries, construc-
ageing of populations tion, ceramics, the metal industries
and initiation of final analysis of a
large post-marketing surveillance
and other dust-generating activities.
study of Norplant contraceptive im-
in the 20th century plants; and the launching of several
Special concerns of women regional initiatives on female genital
Many WHO programmes are now mutilation, acceptability of emer-
is a triumph for addressing womens needs, but few gency contraception, increasing rate
have begun to examine systematically of Caesarean section and quality of
differences between the needs of antenatal care.
the human species.
men and women. Sex-disaggregated
data are needed for any analysis of Older people
gender differences. WHO is develop-
ing a policy on gender and health The challenges of ageing
which should facilitate this work. Sev-
eral of the regional offices are collect- For more people than ever before,
ing data in order to develop national the prospect of a healthy and ex-
and regional profiles of womens tended old age is becoming a reality.
health. People are not only living longer; re-
WHOs norms and standards for search shows that in some cases they
post-abortion care represent best in- are also living in better health, with
ternational practice and form the ba- their rates of disability going down at
sis for the technical support that the same time as their life expectancy
WHO provides to Member States and goes up. For example, the National
other partners. To date, systematic re- Long Term Care Surveys in the
views have been undertaken and rec- United States show significant de-
ommendations issued in relation to a clines in disability prevalence among
range of issues, covering clinical man- older people between 1982 and 1994
agement and complications, post- (Box 20, Fig. 12). On this evidence,
abortion family planning and mana- the world is learning how to grow old
gerial issues. successfully.
The Global Commission on The progressive ageing of
Womens Health focuses on three key populations in the 20th century is a
areas: education for the health of girls triumph for the human species. Glo-
100
Health across the life span
bal population ageing reflects the
unprecedented gains in life expect- Box 20. Living longer, feeling better
ancy described earlier in this report.
It is due to a combination of factors, Biomedical research has had great positive effects on the health and physi-
especially the dramatic declines in cal functioning of the human population; by stimulating the growth of biotech-
infant and child mortality, reductions nology, it has greatly affected the economies of developed nations. These
in maternal deaths, and the benefits effects on the health of the aged in the United States can be demonstrated
that come from overall socioeconomic using data from the National Long Term Care Surveys (NLTCS). Manton and
development improved nutrition, his colleagues at Duke University found that the prevalence rate of chronic
declining infections, better standards disability and institutionalization declined significantly, by almost 15% for the
of living, progress in education, health aged United States population from 1982 to 1994 (age 65 and older). This
care, and biomedical technology. confirmed the decline in chronic disability prevalence of about 8% observed
This ageing trend offers both great from 1982 to 1989 and suggested that the rate of decline in the prevalence
opportunities and formidable chal- of disability among aged Americans had actually increased (to 1.5% per
lenges for all societies. But for many, annum) between 1989 and 1994.
those opportunities may be denied Not only did the prevalence of, and institutionalization rates for, disability
and those challenges may become decline, but the prevalence of many chronic degenerative diseases meas-
unmanageable in the coming century. ured by the NLTCS, and those thought to generate chronic disability, showed
It is essential that the potential social significant reductions. The declines in chronic morbidity suggest that chronic
and economic impacts of improved disability prevalence rates will continue to fall, at least over the period be-
life expectancy are fully appreciated tween the time of chronic disease onset and its eventual progression to a
and acted upon today. The well- stage generating serious chronic disability. Longer-term declines are implied
being of society depends on the good by lower disability prevalence rates, and higher survival rates at age 65-69
health of its older members in their across three elderly cohorts from NLTCS sample populations in 1982 and
later years. For policy-makers and followed to 1991.
individuals alike, this means planning Personal communication from Kenneth G. Manton, Larry S. Corder & Eric Stallard, Center for
for the future. Demographic Studies, Duke University, Durham, NC, USA.
7.5
born in Japan today can expect to live B
to be 80 years old. By 2025 there will J 7.3
J J
be more than 800 million older peo- 7.0 7.1
101
The World Health Report 1998
At present, 13% of the population poning the adverse effects of old age
of the United States is aged 65 and for as long as possible will be a major
above, compared to 4% at the begin- political and personal preoccupation.
ning of the 20th century. The propor- Health-related policies are needed
tion is expected to reach approxi- to tackle the problems faced by those
mately 20% by 2030. Although the already in old age and those who will
population is ageing more slowly in be the older people of the future.
industrialized countries, these coun- Population ageing is having pro-
tries will have relatively more people found effects on society. It is a quiet,
in the oldest old bracket. For ex- almost unseen social revolution that
ample, there were only 200 people is gradually gaining pace and will ac-
aged 100 years in France in 1950. By celerate and become ever more evi-
the year 2000, the number is ex- dent in the next 25 years. Its influ-
pected to rise to 8500, and by 2050 it ence will be felt at every level, from
is projected to reach 150 000 a 750- family life and living arrangements,
Population ageing fold increase in 100 years. employment, the provision of health
The global challenge of ageing is services and pension systems, to the
made more complex by other demo- state of the economy (Box 21).
is having profound graphic changes that are occurring si- In some of the more advanced
multaneously. In the next 25 years, nations, the day is not far off when
the population aged 65 and above is older people will outnumber chil-
effects on society. likely to grow by 88% compared to dren, and the number of people
an increase of 45% in the working- reaching their hundredth year will be
It is a quiet, age population. This implies that a counted in tens of thousands.
steadily declining number of people While society is ageing, it is also
of productive age will have to provide changing in other, related ways. Tra-
almost unseen for an expanding number of depend- ditionally, families have looked after
ants, not merely in the form of direct their older members. Todays old
support to older relatives but also tend to have fewer children to care
social revolution. through taxation, the provision of for them, and in many cases those
health and social services, and social children have grown up and moved
security. away to live at great distances from
their parents.
The social challenge Although daughters and sons are
still the primary caregivers, their
The adults of today are the older peo- ability to care for their older relatives
ple of tomorrow. They are already has been altered by changes in life-
asking: What kind of old age will we styles. Women, the traditional
have? How will it differ from that of caregivers, have increasingly become
our parents and grandparents? What part of the workforce, and so una-
will be our quality of life? What will vailable for their customary role. To
be our place in society? The answers fill these gaps, the community is in-
largely depend on what people do creasingly expected to intervene, by
now as individuals to ensure healthy providing social services, home vis-
ageing, and what governments and its, hospitals, nursing homes, and
communities are prepared to do on sheltered accommodation for its
their behalf. older dependants, and to favour
Maintaining health and quality of community care rather than institu-
life in an ageing population will be tionalized care.
vitally important socially and eco- Already, population ageing is be-
nomically. In the 21st century, post- ginning to revolutionize health care
102
Health across the life span
and social systems, with new public
policies on health and social care Box 21. Disablement and functioning - Towards a common
public and private sector pluralism, language: ICIDH-2
reduction in public spending be-
ing widely adopted throughout the In line with its broad understanding of health, WHO is involved in a global
world. To many observers, these initiative to revise the International Classification of Impairments, Disabili-
trends seem likely to exacerbate the ties and Handicaps (ICIDH) to capture an important paradigm shift towards
disadvantaged position of many older a biopsychosocial understanding of human functioning and disablement. The
people. revised version (ICIDH-2) is a classification of human functioning at the body,
Even in wealthy countries, most person and societal levels that takes into account the social and environmen-
old and frail people cannot person- tal context in which people live.
ally meet more than a small fraction Medical diagnosis alone does not predict health care needs of individu-
of the costs of the health care they als, nor does it predict the utilization, outcomes or costs of health services.
need. At present, it seems clear that Moreover, the presence of a medical condition is not a reliable guide for work
neither developed nor developing performance, disability benefits or social integration of the individual.
countries will be able to provide long- With the increasing importance of chronic and noncommunicable illness,
term, specialized care for the vast the ageing of the population and the increased emphasis on social policy
numbers of aged individuals in the solutions to health issues, a multidimensional classification is urgently needed.
population in the coming decades. As a product of a worldwide consensus-building effort, the revised ICIDH
But this scenario is not inevitable. (renamed International Classification of Impairments, Activities and Partici-
Caring for the aged could be a great pation) will meet the need for an international common language for the
source of new employment. consequences of diseases and other health conditions. ICIDH-2 will also pro-
Most of the increase in older vide users with operational tools for measurement and comparison.
populations will occur in developing The ICIDH-2 will provide a scientific basis for the study of functioning and
countries, which will face the most disablement. It will serve as a common international language, across differ-
serious challenges in providing a wel- ent users and sectors, for global data collection, research, health resource
fare package of services for their allocation and management, and social welfare programming. Because
older people, given their economic ICIDH-2 covers the human experience in all personal and societal domains, it
difficulties, the lack of social service can provide the basis for empirically-grounded policy and legislative change.
infrastructures, and the decline of The ICIDH-2 favours a universal approach to functioning and disablement,
traditional caring provided by family in contrast to the minority model that sees disablement as a defining at-
members. tribute of a minority of people. Disablement is a universal feature of human-
Growing older is associated with ity, manifested for everyone in different levels of functioning.
increasing disability and greater de- Similarly, since human functioning and disablement can only be under-
pendence on others. Generally a per- stood against the background of existing social and physical factors, the
son is regarded as dependent if he or ICIDH-2 includes a classification of contextual factors, i.e. environmental and
she needs the help of another person personal factors that modulate the experience of disablement for individuals.
in order to perform the basic activi- Arising out of a multisectoral partnership involving both providers and
ties of daily living, such as washing, consumers, the ICIDH-2 points in the direction of an invigorated interna-
getting dressed, moving about, eating tional partnership in health care management. As a framework for disable-
and drinking. Most older people will ment, the ICIDH can further the commitment of the United Nations to an
eventually need help of this kind to international disablement social policy founded on human rights and the uni-
some extent. It may be provided by versality of disablement.
any combination of relatives, neigh-
bours, the community and health and
social services, and it may be needed and how that provision is to be
for periods of many years. funded. One obvious way of making
The cost of such help can seldom adequate services available to the
be borne entirely by the older indi- larger numbers needing them is to
vidual or the family. The question impose higher taxes on the working
therefore arises of who bears the cost, population. Increasing taxes, how-
103
The World Health Report 1998
ever, is politically unpopular and have long been recognized as a dis-
many governments are under pres- tinct social category, the starting-point
sure to reduce taxes rather than raise of socially defined old age today is
them, which implies a reduction becoming less clear. In many coun-
rather than an expansion of the serv- tries, old age and the socially accepted
ices in question. roles associated with it are undergo-
Most countries are now seeking ing radical change. Old age is no
alternative types of welfare package, longer accepted unquestioningly as
such as combinations of public sec- beginning at a fixed chronological age,
tor and private sector health insur- such as the point of retirement from
ance and pension schemes, funded by work or the state pensionable age of
direct or indirect taxation and volun- 60 or 65 years.
tary contributions, that will ensure In industrialized countries during
long-term care for older people. much of the second half of the 20th
Sweden has one of the most system- century, most people were led to ex-
As people live longer, atic strategies, with a wide range of pect an abrupt transition from full-
services for older people. Commer- time work to full-time retirement at
cial long-term care insurance plans an age when many of them felt rea-
they must plan are rapidly expanding in the United sonably fit. They also assumed that
Kingdom. In Germany, funding for retirement pensions and welfare serv-
such insurance is predominantly pub- ices provided by the state would be
throughout life lic. A public long-term care insurance adequate to cover their needs in old
programme is likely to be introduced age. These expectations are now be-
to take better care in Japan in the next few years. Half ing fundamentally altered, by indi-
the costs will be paid by premiums viduals, employers and governments.
levied on all those older than 40 years, Individuals are being encouraged to
of themselves. and half will come from general taxa- prepare for old age financially by sav-
tion. In Australia, most long-term care ing and investing more, and staying
is provided by the private sector longer in work.
through a mix of profit and non-profit Many people do not want to re-
organizations. New forms of partner- tire at 60 or 65; about a third of re-
ships between governments and pri- spondents in a survey in the United
vate health insurers are being consid- States felt they had been forced by
ered by some countries, based on circumstances to retire earlier than
schemes already in existence in some they wanted to. In Canada it has been
parts of the United States. This estimated that about 25% of retirees
mixed approach to funding the de- left the workforce involuntarily. The
pendency of older people at a level German government has introduced
broadly capable of meeting needs for measures to make the transition to
care, assistance and accommodation, retirement more flexible, increase the
appears to be gaining support. effective pension age, reduce occu-
pational health risks and stimulate the
The individual challenge creation of new jobs adapted to the
needs of older workers. People who
As people live longer, they must plan want to work longer are being encour-
throughout life to take better care of aged to do so; many of them feel
themselves, on the assumption that a obliged to do so, because of financial
large proportion of their lives will ex- insecurity and uncertainties about
tend beyond what has been tradition- future levels of state assistance.
ally regarded as their most produc- Remaining productive, however,
tive years. Although older people depends on remaining in good
104
Health across the life span
enough health. Individuals therefore women live longer than men an av-
must take greater responsibility for erage of eight extra years in developed
their health at the earliest opportu- countries and tend to marry men
nity. This means adopting habits such older than themselves. However,
as a healthy diet, adequate exercise, some of womens extra years are ac-
and avoidance of tobacco early in life, counted for entirely by years of de-
and maintaining them for the rest of pendency. In the United States, this
their years. means that while only one in seven
Although hereditary factors play men who attain the age of 65 can ex-
an important role in determining life pect to spend a year or more in a nurs-
expectancy and health, the individu- ing home before death, one woman
als lifestyle is, along with the environ- in three at 65 has the same prospect.
ment, one of the greatest modifiable For women in developing coun-
influences. Health promotion, which tries who survive the early life span
is aimed at every other age group, stages to reach middle age, life ex-
does not exclude older people. pectancy approaches that of women As women live
Rather, it aims to stimulate habits and in developed countries. By far the
lifestyles conducive to a better old major factor explaining this trend is
age, and can make a crucial difference reduced maternal mortality, due to longer than men,
in determining how different indi- declining fertility and improved ma-
viduals reach old age. This notion has ternal care. Life expectancies at age
been encapsulated by the term 65 show much greater similarity be-
the quality of
healthy ageing, and is a concept ac- tween developed and developing
tively promoted by WHO and other countries, at around 19 and 15 years their longer life
agencies. Many countries now have respectively. The gap will narrow as
health promotion programmes de- mortality declines not only at younger
signed specially for older individuals, ages but also at later ages. The main becomes of central
covering areas such as physical exer- trend in ageing in developed coun-
cise, healthy nutrition, prevention of tries is the increase in the oldest old,
frailty and injury and chronic disease that is, those 85 years and older. The importance.
management. great majority of this age group are
women, and this trend will continue
The gender challenge in the foreseeable future.
As women live longer than men,
Women make up the majority of the the quality of their longer life be-
older population in virtually all coun- comes of central importance. Qual-
tries. In at least 67 developing coun- ity of life, measured in terms of older
tries, the projected increase in the womens capacity to maintain physi-
number of women aged over 65 years cal, social and mental well-being not-
between 1997 and 2025 exceeds withstanding varying levels of illness
150%. During the same period, the and disability, is of as much relevance
number of older women in Asia (pres- as increased life expectancy and years
ently 107 million) is projected to soar of life free of disability. The major
to 248 million, and in Africa, from 13 preventable causes of morbidity and
million to 33 million. mortality all take effect over extended
Women have different circum- time periods. Primary prevention
stances, challenges and health con- strategies will be most effective when
cerns from men as they age. Older initiated as early as possible. Coronary
women are more likely to be wid- heart disease, stroke and lung cancer
owed, to live alone and to live in pov- are the conditions which primary pre-
erty. Largely this is because globally vention needs to address, while sec-
105
The World Health Report 1998
ondary prevention strategies are ap- oporosis; neurological or mental dis-
plicable to other cancers. orders such as dementia and depres-
Taking action to improve the sion; degenerative disorders such as
health of ageing women is imperative loss of sight and hearing; and chronic
if they are to achieve an acceptable obstructive pulmonary disease.
quality of life in their extended old The paramount health challenge
age and if all societies are to avoid the must be to prevent, postpone or treat
consequences that otherwise will en- these conditions. It is a challenge best
sue. The health of older women met by a partnership of individuals
therefore receives special attention and health care providers. The great
in the following section. However, the variation in rates of chronic diseases
very fact that it is a special issue illus- around the world shows that many
trates another reality: by this stage of can in fact be prevented, or at least
womens lives, most of their male con- delayed. For example, age-specific
temporaries have died. The reasons rates for cardiovascular disease have
Ageing is a normal why men die sooner than women is halved in Japan and the United States
also an issue which needs further in- in the past 30 years. Cancer and heart
vestigation. disease are more related to the 70-75
dynamic process. age group than any other, but beyond
The health challenge 75 years exists another population
the oldest old who have survived this
It is not a disease. Ageing is a normal dynamic process. hazardous phase of life. They have
It is not a disease. While ageing is in- now become more prone to impair-
evitable and irreversible, the chronic ments of hearing, vision, mobility and
disabling conditions that often accom- mental function.
pany it can be prevented or delayed, The following section refers to the
not only by medical interventions but major chronic conditions mentioned
more effectively by social, economic above, with special reference to their
and environmental interventions. significance in women.
The longer older people remain
in good health, disability-free and Circulatory diseases
productive, the better will be their
quality of life and the greater their The increasing number of older peo-
contribution to society, and perhaps ple in all societies and the high bur-
the smaller will be the cost of pro- den of cardiovascular disease (CVD)
viding health and social services for in older people make it urgent that
them. Equally, the longer the health appropriate health policy recommen-
of the working population can be dations are made for this group. Over
sustained without disability, the more 80% of deaths from CVD occur in
productive it will be and the more people over 65. Worldwide, CVD is
able to support older dependants. the leading cause of death and dis-
This will also benefit the working ability in people over 65, but there is
population as it ages. great potential for treating it.
Healthy life expectancy is influ- The high prevalence of CVD risk
enced by a relatively small number of factors in older people, particularly
chronic disabling conditions that be- raised blood pressure and raised se-
come more common with increasing rum cholesterol, suggests the need for
age. They include circulatory dis- widespread treatment. Management
eases, such as cardiovascular disease of mild elevations of blood pressure
and stroke; cancers; musculoskeletal can be achieved by non-pharmaco-
conditions such as arthritis and oste- logical measures, including reduction
106
Health across the life span
of salt and excess alcohol consump- quitting increases, but some benefits
tion, and physical activity. Moderate are realized immediately. For exam-
to severe hypertension can be ple, stroke risk decreases after two
treated with diuretics and beta- years abstinence and becomes the
blockers. same as that of never-smokers after
Elevated serum cholesterol is five years.
common in older people and is a risk In developed countries, there has
factor for coronary heart disease been a consistent decline in stroke
(CHD) in both men and women, and mortality over the last 40 years, with
this relationship persists into very old an acceleration in this decline in the
age. As with younger people, drug mid-1970s. The fall in stroke deaths
therapy should be considered only has been greater than that in deaths
after serious attempts at modifying from CHD. For example, in Canada,
diet have been made. Japan, Switzerland and the United
Intervention trials have shown States stroke mortality has declined
that reduction of blood pressure by 6 by more than 50% in men and women Management of mild
mm Hg reduces the risk of stroke by aged 65-74 since the 1970s. Although
40% and of heart attack by 15%, and the reasons are not fully understood,
that a 10% reduction in blood cho- the limited evidence available sug- elevations of blood
lesterol concentration will reduce the gests that a decline in case-fatality
risk of coronary heart disease by 30%. may be related to decreased severity
Dietary changes seem to affect risk of the disease, with the acute event
pressure can be
factor levels throughout life and may becoming more mild, probably as a
have even more impact in older peo- result of prevention efforts. Improved achieved by
ple. Relatively modest reductions in management in the acute phase may
saturated fat and salt intake, which also have contributed.
would reduce blood pressure and As increasing age is considered to non-pharmacological
cholesterol concentrations, could be the main risk factor for stroke and
have a substantial effect on reducing circulatory diseases more generally,
the burden of cardiovascular disease. the burden of these diseases will be- measures, including
Increasing consumption of fruit and come heavier as greater proportions
vegetables by one to two servings of the population in developing coun-
daily could cut cardiovascular risk by tries reach older ages. reduction of salt
30%. Coronary heart disease and stroke
Cigarette smoking is the most are the major causes of death and dis-
important modifiable risk factor for ability in ageing women. The com- and excess alcohol
CVD in young and old alike. Fortu- mon view that they are mens health
nately it is usually less prevalent in problems has tended to obscure their
older people than in younger people. significance for ageing womens consumption, and
The dramatic decline in cigarette health and there is a need to bring
smoking in some wealthy countries their importance into sharper focus.
shows that smokers can be persuaded They account for close to 60% of all
physical activity.
to give up. adult female deaths in a typical de-
For example, in the United States veloped country, and are also the
smoking declined in men aged 65 and major cause of death among women
above from 28% in the mid-1960s to aged 50 years and above in develop-
15% in 1990. However, in women in ing countries. In the majority of de-
the same age group there was an in- veloped countries for which trend
crease from 10% to 12%. Reductions data are available, declines in death
in stroke and CHD rates from smok- rates from heart disease and stroke
ing cessation increase as time since have been greater for women than
107
The World Health Report 1998
men, but cardiovascular disease will average deprives women of 10 years
continue to be the major health issue of life expectancy, while prostate can-
for older women. Improvements in cer reduces male average life expect-
death rates have been much smaller ancy by only one year.
in many developing countries. As a result of medical advances,
Women are usually 10 years older one-third of all cancers are prevent-
than men when symptoms of heart able, and a further one-third, if diag-
disease first appear, and may be up nosed sufficiently early, are curable.
to 20 years older before a heart at- For the remaining one-third, appro-
tack occurs. In the United States, 55% priate palliative care can bring about
of women over 75 years with coronary substantial improvements in the qual-
heart disease are disabled by their ill- ity of patients lives.
ness. The disease will probably be- The five leading cancer killers
come epidemic in older women un- worldwide are also the five most com-
less they take preventive action mon in terms of incidence. Together
Most cancers arise throughout their lives, yet studies they account for about 50% of all can-
show that women do not usually count cer cases and deaths. Among men, the
heart disease among the health prob- leading eight killer sites for cancer are
at an advanced age, lems they consider most important. the lung, stomach, liver, colon-rec-
The impact of increased smoking tum, oesophagus, mouth-pharynx,
rates among women is now becom- prostate, and lymphoma. In women
and the risk ing more evident. Death rates from they are cancers of the breast, stom-
smoking-related diseases have ach, colon-rectum, cervix, lung, ovary,
increases steeply plateaued in men whereas they are oesophagus and liver. The major killer
increasing in older women. Cigarette cancer in women in developing coun-
smoking by women has not yet be- tries is breast cancer, followed by
with age. come widespread in developing coun- stomach cancer. In developed coun-
tries, and there is still time to take tries, breast cancer also ranks first, fol-
global action to protect older women lowed by colorectal cancer.
from diseases due to smoking. An analysis of the risk factors in-
volved in the development of the
Cancer major cancers shows that a few ma-
jor factors dominate tobacco, diet,
The gradual elimination of other fa- alcohol, infections and hormones all
tal diseases, combined with rising life of which lend themselves to preven-
expectancy, means that the risks of an tive actions. The long latent period for
individual developing cancer during most cancers dictates the importance
his or her lifetime are steadily increas- of early detection.
ing. Most cancers arise at an advanced In terms of prevention, screening
age, and the risk increases steeply for cervical cancer has contributed to
with age. The cancer burden is there- steep declines in this disease in many
fore much more important in countries. To combat breast cancer,
populations having long life expect- mammography is now generally pro-
ancy, relative to other groups of dis- posed for women over 50 in those
eases. countries where the disease has a high
As shown in The World Health incidence. Prostate cancer, most com-
Report 1997, the average age at death mon in men over 70 years, also lends
from six of the most common forms itself to early detection, although the
of cancer ranged from 61 to 69 for a value of screening is debated.
sample of six countries. In France and Lung cancer is the most prevent-
the United States, breast cancer on able of all cancers as over 90% is at-
108
Health across the life span
tributable to smoking. Levels of mor- have led to an increase in the pro-
bidity and mortality among older portion of women who are over-
women due to lung cancer are now weight or obese. By contrast, in de-
similar in developed and developing veloping countries it is the excessive
countries, and likely to grow world- physical demands on women
wide, given the increasing numbers throughout their life that most ad-
of women who smoke. Lung cancer versely affect physical strength and
in women has increased fourfold over mobility. Dealing with heavy loads
the last 30 years in many developed leads to damage of the joints. In ad-
countries, and has overtaken breast dition, nutritional deficiencies re-
cancer as the leading cause of cancer duce the physical strength of women
death in women in the United States, as they age. In developed countries,
where women first took up smoking undernutrition is a problem among
in large numbers. This pattern is be- the oldest of old women.
ing repeated elsewhere in developed Osteoporosis and associated frac-
countries, where between one- tures are a major cause of death, ill- For ageing
quarter and one-third of women have ness and disability, and a cause of
started smoking. In many Latin huge medical expense worldwide.
American countries, up to two-thirds Bone fractures are the main compli- men and women,
of young women smoke; levels are cation, and given that they are most
considerably lower in most African common in older people, the influ-
and Asian countries. ence of increasing life expectancy on
exercise is
the number and regional distribution
Chronic obstructive pulmonary of hip fractures will be dramatic. an important
disease (COPD) Worldwide, it is estimated that the
number of hip fractures could rise
This category includes chronic bron- from 1.7 million in 1990 to around 6.3 preventive activity.
chitis and emphysema, which are es- million by 2050. Women represent
pecially prevalent in older age groups. 80% of those who have a hip fracture;
Although these conditions are more their lifetime risks for osteoporotic
common in men, their prevalence in fractures are at least 30% and prob-
women will undoubtedly increase, ably closer to 40%. In men, the risk is
because cigarette smoking is the main 13%.
risk factor, and smoking among Women are more prone because
women is globally on the rise. The their bone loss accelerates after the
direct cost of managing COPD, which menopause. Prevention is possible
frequently requires hospitalization, is with hormone therapy at the meno-
high. Most deaths due to COPD oc- pause. Lifestyle factors are also asso-
cur after the age of 65. ciated with osteoporosis (diet, physi-
cal activity, smoking), opening a per-
Musculoskeletal conditions spective for primary prevention. The
primary aim is to prevent fractures:
These conditions reduce mobility this may be achieved by increasing
and agility, and so have a major im- bone mass at maturity, by preventing
pact on self-care. For ageing men subsequent bone loss or by restoring
and women, exercise is an important the bone mineral. Lifestyle modifica-
preventive activity against all major tions, particularly increased calcium
musculoskeletal conditions. Yet few intake and physical activity, could be
older women exercise on a regular of great importance.
basis in developed countries. Lack of
exercise and inappropriate nutrition
109
The World Health Report 1998
110
Health across the life span
eases, mental health, prevention of More than 100 countries have set
respiratory infections, family life and up blindness prevention pro-
support, prevention of accidents, and grammes, and many of these have
health promotion. Published in 1984, been highly successful in reducing
The uses of epidemiology in the study certain causes of blindness, such as
of the elderly stimulated new ap- trachoma. The main constraints are
proaches to research on ageing. Ac- insufficient resources for large-scale
tivities from the late 1980s to the mid- provision of care, such as cataract sur-
1990s were focused on determinants gery. Recent developments in new,
of healthy ageing, osteoporosis and low-cost technology are very promis-
age-associated dementias. In 1994, ing (e.g. intraocular lenses), but need
the programme was reoriented to- to be made available on a large scale
wards ageing and health. in developing countries.
Today, the WHO programme During 1997, a WHO Alliance for
deals with both old age and ageing. It the Global Elimination of Trachoma
sees older people as not compart- was established, to intensify action More than
mentalized but part of the life cycle. against that disease together with in-
It emphasises health promotion, with terested nongovernmental organiza-
a focus on healthy ageing, or ageing tions and other partners, making use 100 countries have
well. It takes account of gender dif- of new methods for rapid assessment
ferences evident in both health and and more effective treatment of the
ways of living, and the cultural set- disease. Other collaborative activities
set up blindness
tings in which individuals age deter- have included support to cataract sur-
mine their health in older age. It is gery in Africa, planning for eye care prevention
concerned also with strategies to in China and in Haiti, and an eco-
maintain cohesion between genera- nomic analysis of blindness preven-
tions and the many ethical issues of tion. WHO has also undertaken ap- programmes.
population ageing. plied research, in collaboration with
An expert committee on determi- the United States National Eye Insti-
nants of healthy ageing is scheduled tute on cataract surgery in India, and
to meet in 1998 to discuss these per- specific evaluations of national pro-
spectives in depth. This committees gramme results in China and Nepal.
guidance will be sought on how WHO In the Americas, 26 countries are
and its Member States can best play developing ocular health services to
a major role in presenting the health address the major problems of cata-
component of the International Year racts, diabetic retinopathy, glaucoma,
of Older Persons (1999). and the need for inexpensive eye-
Other WHO activities are directed glasses.
towards specific aspects of the health Work for the prevention of hear-
of older people. For example, the main ing impairment has included field-
strategies for preventing blindness and testing of uniform assessment proce-
deafness have focused on the devel- dures in selected countries, and de-
opment of national programmes based velopment of strategies against noise-
on primary health care induced hearing loss.
111
The changing world
Chapter 4
The changing world
E
conomic and social gains dur- from less than 50% in 1970 to more
ing the past 50 years have than 75% in the early 1990s; and the
been dramatic and unprec- proportion of children attending
edented, particularly for developing school rose from less than half to
countries. Though the global popu- more than three-quarters. During the
lation doubled during the period, per last two decades, coverage of infants
capita gross domestic product (GDP) with immunization against the six
increased by at least 2.5 times, GDP major vaccine-preventable diseases
more than five times and exports reached more than 80%. However,
more than 10 times (Table 7). Con- the pace of such postwar progress has
siderable progress has been made in been neither steady nor uniform, as
reducing the incidence of absolute the following analysis will show.
poverty (with a more modest reduc-
tion in the number of poor) and in Economic trends
achieving somewhat better living
standards for those who have re-
mained in poverty. Growth of the economy
Social gains have also been signifi-
During the period 1950-1973, the
cant during the past 50 years. Life ex-
world experienced a golden age of un-
pectancy at birth increased from 46
paralleled prosperity with unusually
years in the early 1950s to 64 in the
favourable performance of the
early 1990s, and infant mortality rates
economy and dynamism observable
declined from 156 per 1000 live births
in all regions. World per capita GDP
to 62 per 1000 during the same pe-
grew by about 3% a year more than
riod. Food supply has more than dou-
three times as fast as during the ear-
bled in the past 40 years, much faster
This chapter is largely based on the latest lier half of the 20th century from
available publications of other international than population growth, and the pro-
about $ 2140 in 1950 to $ 4120 in
agencies with respect to areas under their portion of people chronically under-
responsibilty. Detailed references can be found 1973. However, the overall long-run
nourished fell from about one in three
in the statistical annex. pattern of income spreads between
to one in five. Adult literacy rates rose
1950 and 1973 was strikingly diver-
gent. The intercountry spread in per
Table 7. Growth of GDP and GDP per capita,a capita GDP grew steadily larger from
Growth of GDP GDP per capita 35 to 1 in 1950, to 40 to 1 in 1973
(annual percentage change) (US $) (but then there was also a catch-up
phenomenon). Economic growth was
1981-1990 1991-1996 1980 1996 1997
interrupted around 1975 by a sharp
World 3.1 3.3 4 883 5 966 6 123 reduction, possibly resulting from
Developed market economies 2.8 1.7 16 547 21 995 22 497 strong inflationary pressure, the
Economies in transition b 2.0 -6.4 5 464 4 012 4 062
breakdown of the fixed exchange rate
Developing countries 3.8 5.8 2 102 3 147 3 282
system and the sudden rise in oil
of which LDCs 2.4 3.5 1 097 1 132 1 159
prices. The momentum of the earlier
a
b
On the basis of purchasing power parity. period has never been regained since,
Including the former German Democratic Republic until 1990.
except in East Asia.
113
The World Health Report 1998
During the period 1973-1993, tion has been due more to a broaden-
most of the world economy operated ing of the numbers of growing coun-
below its potential (possibly accentu- tries than to faster rates of growth in a
ated by a retardation of technical limited number of countries. While
progress). This was particularly true such a broadening of the reach of eco-
of eastern Europe, Africa and Latin nomic growth in developing countries
America. Asia was the brightest spot to include an increasing number of the
in the world economy during the pe- lower-income countries represents a
riod. Average GDP growth was the heartening contrast to the situation in
same as in the golden age, but popu- the 1980s, many least developed coun-
lation growth slowed down and per tries have not yet achieved these
capita growth accelerated. Average higher rates of growth. For many low-
per capita production rose by 80%. income African countries, maintaining
Western European countries had higher rates of growth is imperative for
much slower growth than in the achieving even a moderate level of in-
Beneath the golden age. The deceleration in GDP, come per capita within a reasonable
per capita GDP and labour produc- time. Although output per capita in
tivity was quite sharp. However, the Africa fell on average in the 1980s and
apparently modest results were in most cases superior to in the early 1990s, the stronger growth
anything these countries had experi- of output at about 4% over the past
enced before the postwar golden age. two years, and the expectation that
performance of They continued to increase the open- such an improvement in economic
ness of their economies after 1973, growth could also be sustained, is a
the world economy and the ratio of trade to GDP in- dramatic change from the past.
creased substantially and continued In spite of earlier experiences with
their catch-up on American produc- episodes of relatively rapid growth
in the early 1990s tivity. However, they began experi- followed by widespread slowdown
encing rising rates of unemployment. and even recession in many countries,
As governments concentrated on the IMF visualizes that, with the com-
were political, policies for the restoration of price bination of the strong catch-up poten-
stability to counter the threat of hy- tial of the developing and transition
perinflation, economic growth and countries, and the beneficial effects
economic and full employment became secondary on productivity of technological ad-
considerations. In Australia, Canada, vances and increasing globalization,
New Zealand and the United States, the current expansion of the world
technological there was also a slowdown in growth economy can be sustained possibly
after 1973, an acceleration in inflation into the next decade. The sustainable
and a rise in unemployment rates. rate of growth of world output may
upheavals. During the period since 1993, also be somewhat stronger than in the
when the economic recovery started, quarter-century since the first oil
the world economy has been grow- shock of the mid-1970s.
ing at an annual rate of about 3.5%. Beneath the apparently modest
World output is expected to expand performance of the world economy
by more than 4% in both 1997 and in the early 1990s were political, eco-
1998, the strongest pace in a decade; nomic and technological upheavals
the global economy has been enjoy- which will have a far-reaching impact
ing the fourth episode of relatively on future prosperity for the world.
rapid growth since the early 1970s. The changes include the increasing
The rate of growth of the develop- global integration of economic activi-
ing countries as a group has been at its ties and market-oriented institutional
highest in many years. This accelera- reforms in many countries. More
114
The changing world
countries are looking to global inte- estimates that the middle strata of
gration as an important vehicle for developing countries (with incomes
improving their economic perform- between 40% and 80% of the aver-
ance. However, history suggests that age in developed countries) are
without a sufficiently broad social shrinking today more than in the
consensus in favour of integration, 1970s, not because they have gradu-
and international macroeconomic sta- ated to the status of more advanced
bility, further improvements in eco- countries but because for many of
nomic performance could be under- them rates of growth of per capita in-
mined. come have not been fast enough even
A main driving force behind many to stay in that intermediate category.
recent political and economic A major constraint inhibiting fur-
changes has been the acceleration in ther economic growth and interna-
technological innovation, especially tional macroeconomic stability has
the revolutionary changes in informa- been the debt burden of the devel-
tion technology. Technological inno- oping countries, particularly of the Polarization among
vations will not only improve produc- heavily indebted ones. However, 13
tivity and economic structures, they of the 51 countries classified by the
will also have an important impact on World Bank as severely indebted countries has been
economic institutions and will bring were middle-income countries an
changes in social superstructure. With indication that debt vulnerability was
such an improvement in productivity not an exclusive feature of the poor-
accompanied by
through technology, there are est countries. 19 of the 51 countries
grounds for optimism about the fu- are from regions other than Africa, increasing income
ture of the world economy. A major reaffirming the broader scope of the
issue is whether there will be a con- problem. Continued domestic policy
vergence, with the poorer countries efforts to ensure better utilization of inequality within
achieving a faster economic growth the existing capacity to produce goods
than the richer. and services, combined with external
debt relief and the transfer of new countries.
services, are essential for a broad-
Increasing inequalities based recovery in these countries,
and global debt burden particularly the heavily indebted poor
countries (HIPCs) in Africa. It is ex-
A recent review by the United Na-
pected that with a speedy and flex-
tions Conference on Trade and De-
ible implementation of the HIPCs
velopment (UNCTAD) suggests that
Debt Initiative, a lasting solution to
since the early 1980s, the global
the debt crises of the HIPCs in all
economy has been experiencing ris-
regions (including Africa) may be
ing inequality. Income gaps between
possible.
countries have continued to widen. In
Polarization among countries has
1965, the average per capita income
also been accompanied by increasing
of the G7 industrialized countries was
income inequality within countries.
20 times that of the worlds poorest
The income share of the richest 20%
seven countries. By 1995 it was about
of the population has risen almost
50 times greater. Though a number
everywhere since the early 1980s, in
of developing countries have been
many cases reversing a postwar trend.
growing faster than the developed
In more than half of the developing
market economies, growth rates were
countries the richest 20% today
not fast enough to narrow the abso-
receive over 50% of the national
lute per capita income gap. UNCTAD
income. Those at the lower end of the
115
The World Health Report 1998
income scale have failed to see real tential gains of specialization through
gains in living standards, and in some changes in production structure and
cases have had to endure real losses. division of labour.
In many countries, the per capita in- A large-scale shift in the world
come of the poorest 20% now aver- production structure has already oc-
ages less than one-tenth that of the curred in all regions. By 1992, agri-
richest 20%. Such a trend towards a culture accounted for only 7% of
widening of gaps between income world production, compared with al-
groups is apparent in both more and most 14% in 1960, while services
less successful developing countries. reached 58%. The share of the de-
Evidence is mounting that slow veloped market economies in manu-
growth and rising inequalities deter- facturing declined from 87% in 1960
mining international and national di- to 77% in 1992. In petroleum refin-
visions can no longer be considered ing and mining, about 25% of the to-
as merely temporary adjustments to tal capacity of the developed market
Increasing a rapidly changing world economy economies shifted to the develop-
they are becoming more permanent ing countries, mainly Latin America.
features. If this situation continues, There were also relative shifts of 15-
unemployment there is a real threat of a political 20% from developed to developing
backlash following radical differences countries of world production in tex-
in thought, action, values, tastes and tile and wearing apparel, in non-
among the educated feelings that will create a new politi- ferrous metals and steel production.
cal geography divorcing the interests These interregional shifts were ac-
may wipe out several of the rich from the welfare of the companied by large-scale domestic
poor. Increasing unemployment restructuring in most regions. Such a
among the educated is another fac- process of worldwide structural
of the benefits tor which should not be overlooked. change is driven by technical advance
This may wipe out several of the ben- and increased global interdepend-
efits of recent economic reforms in ence. Research in this area shows that
of recent economic developed and developing countries investment in human capital health
alike. and education and in technology has
been a major factor contributing to
reforms. Sectoral changes and more rapid growth and to a faster
convergence of countries through
emerging opportunities accelerated improvements in long-
run economic performance.
Though economic convergence is not
Thus, technological advances of-
a global characteristic, there has been
fer opportunities that could be ex-
convergence among certain groups of
ploited. Developing countries could
countries (particularly in what are to-
judiciously take advantage of the
day developed countries and regions)
multitude of technologies already
in a large part of Asia and, to a lesser
available to catch up, and of a
extent, in Latin America where
healthy workforce to sustain growth
growth has recently been faster than
and build on it their prosperity. Poor
that of the developed ones. Apart
countries whose main resource is la-
from investments in education and in
bour could make their workforces
research and development that have
more productive, not just through ris-
contributed to more rapid economic
ing education standards but also
growth, these countries highlight the
through learning by doing as new
importance of policies and institu-
production techniques are intro-
tions that allow them to capture po-
duced. This requires the creation of
116
The changing world
an environment that would facilitate lion (8.6%) in 1975, 579 million
substantial investments both domes- (10.2%) in 1995 and is expected to
tically and internationally, to create reach more than 1.2 billion (14.4%)
jobs and raise education standards. in 2025.
The World Health Report 1995 iden- The world population grew at an
tified enhancement of the health po- annual rate of 1.98% during 1955-
tential of the current workforce and 1975, 1.67% during 1975-1995 and is
future workforce (schoolchildren) as expected to grow annually by 1.16%
a top priority for achieving not only during 1995-2010. Despite the de-
social progress but also sustainable cline in the rate of growth, the annual
economic growth through increased increment to the world population
labour productivity, and for ensuring will remain steady at about 80 million
that the poor earn their way out of per year until 2010, when it will
poverty. gradually decline to about 40 million
per year between 2045 and 2050,
about half of the current annual in- The annual increment
Population trends crement. The 48 LDCs are, however,
characterized by higher fertility,
The newly revised estimates by the higher mortality and higher popula- to the world
United Nations Population Division tion growth rates than the other de-
of the global population confirm veloping countries. Between 1955
broadly the conclusions of the earlier and 1975, the population of what are
population will remain
revision, notably slower population today LDCs increased by 61% com-
growth, lower levels of fertility, more
diverse trends in mortality and
pared with 59% for other developing steady at about
countries. For 1975-1995, percentage
greater migration flows during the increases were respectively 66% and
first half of the 1990s than experi-
enced in previous decades. The 1996
47%, and for 1995-2025, they are ex- 80 million per year
pected to be 100% and 44%. Overall,
revision showed a more rapid decline for every 100 persons added annually
in population growth, national fertil- to the world population, the contri- until 2010.
ity declines were broader and deeper, bution of developing countries (other
and migration flows were larger than than LDCs) was 74 during 1955-1975
previous estimates. and 77 during 1975-1995, but is ex-
pected to decline to 72 during 1995-
Population size and growth 2025. Similar figures for the LDCs
are 10, 14 and 25 respectively.
The global population was 5.8 billion
in 1997. It was about 2.8 billion in
1955, 4.1 billion in 1975 and 5.7 bil-
International migration
lion in 1995, and is expected to reach and refugees
8 billion by 2025. The developing
countries, excluding the least devel- Internal conflicts and disintegration
oped ones, had a population of 1.7 of nation-states resulted in significant
billion (60% of the global population) population movements particularly in
in 1955, 2.6 billion (64.7%) in 1975, respect of refugees, asylum seekers
3.9 billion (68.1%) in 1995 and are and displaced persons. The United
expected to reach 5.6 billion (69.2%) Nations Population Division has es-
by 2025. The global share of what are timated that the number of interna-
today called least developed countries tional migrants in the world rose from
(LDCs) was 217 million (7.9% of the 75 million in 1965 to 120 million in
global population) in 1955, 350 mil- 1990 an annual growth rate of 1.9%.
117
The World Health Report 1998
Fig. 13. Population by age and sex, 1995 and 2025 The rate rose from 1.2% during 1965-
1975 to 2.2% during 1975-1985 and
LYT 980
World reached 2.6% during 1985-1990.
Age Despite this accelerating growth, by
80+
2025 75-79
70-74
1990 international migrants ac-
1995 65-69
60-64
counted for only 2.3% of the worlds
55-59
50-54 total population. However, their dis-
45-49
40-44 tribution by region was far from uni-
35-39
30-34
25-29
form.
20-24
15-19
In Australia and New Zealand, in-
10-14
5-9 ternational migrants made up 18% of
0-4
10 8 6 4 2 0 0 2 4 6 8 10 the total population in 1990; in west-
Developed market economies ern Asia, nearly 11%; in North
Age
80+ America, less than 9%; in the tradi-
75-79
70-74 tional market economy countries of
65-69
60-64
55-59
Europe, over 6%; and in Asia (exclud-
50-54
45-49 ing western Asia), Africa and Latin
40-44
35-39 America, less than 2.5%.
30-34
25-29
20-24
Net international migration con-
15-19
10-14
tributed 45% of the overall popula-
5-9
0-4 tion growth in the developed world
10 8 6 4 2 0 0 2 4 6 8 10
for 1990-1995, but it lowered slightly
Developing countries (excluding LDCs) the overall growth rate of the popu-
Age
80+
75-79
lation in the developing world by
70-74
65-69 3 %. Whereas the annual growth rate
60-64
55-59 of international migrant stock in the
50-54
45-49
40-44
developed world increased only mod-
35-39
30-34
erately from 2.3% per year during
25-29
20-24 1965-1975 to 2.4% during 1985-1990,
15-19
10-14 the annual growth rate of the total
5-9
0-4 number of migrants in the develop-
10 8 6 4 2 0 0 2 4 6 8 10
Least developed countries ing world increased ninefold, from
Age 0.3% during 1965-1975 to 2.7% dur-
80+
75-79
70-74
ing 1985-1990. Despite the rapid
65-69
60-64 growth of the number of international
55-59
50-54 migrants in the developing world, by
45-49
40-44
35-39
1990 the proportion of international
30-34
25-29
migrants among the total population
20-24
15-19 of the developing world remained low
10-14
5-9 at 1.6%, as against 4.5% of the popu-
0-4
10 8 6 4 2 0 0 2 4 6 8 10 lation in the developed world. How-
Males Females ever, in Europe almost 88% of the
Percentage of total population by level of development
population growth during the period
1990-1995 was attributable to interna-
tional migration, with unemployment
of the educated in the developing
countries being a contributing factor.
Refugees are an important compo-
nent of the number of international
migrants in the world. The total
number of refugees worldwide is esti-
118
The changing world
mated to have increased markedly dur- countries during 1975-1995, there Fig.14. Age structure of the
ing 1985-1990, going from 10.5 mil- was an overall increase of 74 million global population, 1955-2025 a
lion to 14.9 million and accounting for in the developing world, more than
12.4% of the worlds migrant stock in 40% of which concerned the LDCs. Age groups
1990. In fact, the refugee stock During 1995-2025, however, it is ex- <20
reached a maximum early in 1993, pected that the child population will 20-64
when it stood at 18.2 million. Since decrease by 6 million in the devel- 65+
then, the number of refugees has been oped countries but increase by 54 1955
decreasing so that by early 1996 it million in the developing world, more 5%
(0.1)
stood at 13.2 million. This decline has than 90% of which will concern the
resulted from major repatriations LDCs. Elderly support
made possible by the solution of sev- Overall there is also a shift in the ratiob: 10.5
eral long-standing conflicts and from composition of the dependency ratios 50% 45%
the growing reluctance of countries of (Fig 14). For every 100 young de- (1.4) (1.2)
asylum to grant refugee status. pendants aged less than 20 years in
1955, there were 12 older dependants
Age composition and aged 65 and above. In 1975 the ratio
was 100 to 12, in 1995 it was 100 to 1975
dependency ratios 16 and by 2025 there are expected to 6%
(0.2)
In 1997, there were about 2.3 billion be 31 older dependants for every 100
young persons aged less than 20 years young dependants. Elderly support
The number of women of child- ratiob: 11.8
in the world (40% of the total popu-
lation). Children under 5 constituted bearing age (15-49 years) increased 47% 47%
10% of the world population, and annually by 1.8% during 1955-1975 (1.9) (1.9)
older persons 7% (389 million). The and by 2.1% during 1975-1995, and
rest were aged 20-64 years. is expected to increase by 1% per year
Population growth not only varies during 1995-2025, an increase of 522
million. Adolescent women aged 15- 1995
by level of development, there are
19 account for about 20% of all 7%
also differential rates of growth of (0.4)
various components of the global women of reproductive age now in
population (Fig 13). For example, the the developing world, but are ex- Elderly support
ratiob: 12.3
global population of children grew at pected to represent 16% by 2025. 40%
1.57% per year between 1955 and Worldwide the number of these (2.3)
53%
1975, 0.6% between 1975 and 1995 women will increase by at least 56 (3.0)
and is expected to grow by 0.25% million during 1995-2025, rising to
between 1995 and 2025. The older 307 million by 2025, most of them in
population aged 65 and above, how- the developing countries..
2025 LYT 98012
ever, increased by 2.3%, 2.4% and
2.6% respectively during these peri- Fertility 10%
(0.8)
ods. Of the 140 million increase be-
tween 1975 and 1995 in the popula- The total fertility rate (TFR) the Elderly support
32%
ratiob: 17.2
tion aged 65 and above, 46 million number of births per woman of child- (2.6)
(33%) is attributable to the developed bearing age has been declining from
58%
countries and 7 million (5%) to the 5 in 1955 to 4.2 in 1975 and to 2.9 in (4.7)
LDCs. Increases for the period 1995- 1995. It is expected to reach 2.3 by
2025 are estimated to be 91 million 2025. The world average, however,
(21%) for the developed countries conceals large differences among
and 28 million (6%) for LDCs. countries and regions. TFRs in 1995
a
Though the child population de- ranged from 1.2 in Italy to 7.6 in Percentages of total global population; figures in
brackets refer to the number of persons in billions.
creased by 8 million in the developed Yemen. In 1995 the TFR for the de- b
Elderly support ratio: population aged 65 and above
veloped world was only 1.7 compared as a percentage of the population aged 20-64.
119
The World Health Report 1998
Fig. 15. Replacement-level with 5.4 for the LDCs. However, cess to temporary methods of contra-
fertility, 1955-2025 a there is convergence in the TFRs ception. In Latin America and the
among countries, mainly due to in- Caribbean and in Asia, the proportion
creasing contraceptive prevalence was over 80% and in Africa nearly
1955 worldwide. While the TFR for the 60%. However, at least 350 million
2.1 or below
0.1% LDCs was about 4 times that of the couples worldwide now lack access to
western European value in 1980, it the full range of modern family plan-
was only 3.7 times in 1995. This ratio ning methods sterilization, IUD, pill
is expected to decline further to 1.8 and condom. Globally 120-150 mil-
by 2025. The TFR declined in all re- lion married women wish either to
above 2.1
gions except North America, which have no more children or to delay
99.9%
recorded an increase from 1.8 in 1980 their next birth at least two years, but
to 2 in 1995. During the same period are not using any method of family
Africa continued to have a high fer- planning.
tility rate, although it decreased from For the world as a whole, the
1975 6.4 to 5.5 compared with decreases number of women of reproductive
of 4.1 to 2.8 in Latin America and 4 age in 2025 is expected to be 1.6 times
2.1 or below to 2.7 in Asia. However, large regional higher than in 1990, and the number
21% differences also prevail within Africa, of married women to grow slightly
particularly between northern and less (to 1.5 times the number in
above 2.1 southern Africa and the rest of Africa. 1990). It is also expected that contra-
79% While in the 1970s sub-Saharan coun- ceptive prevalence among them will
tries had high TFRs in the 1990s most increase globally to 62% by the year
of them experienced substantial de- 2000 and to 70% by 2025. Similar fig-
clines, the largest being in Kenya, ures for the developed world are 74%
1995 where it fell from 8 in 1977-1978 to and 75%, and for the developing
5.4 in 1990-1993. world 60% and 70% respectively. This
It is also expected that if this trend means that the number of contracep-
2.1 or below continues, the number of countries tive users will need to increase by 50%
45% achieving a level less than or equal to even to maintain prevalence at the
the replacement level of 2.1 births per current level. To increase it from 60%
above 2.1 woman would increase from 3 coun- to 70%, the number of contraceptive
55% tries (0.1% of the global population) users among married women will
in 1955 to 102 countries (76%) by have to be nearly twice as high in 2025
2025 (Fig. 15). as in 1990, a challenge for the repro-
Contraceptive prevalence is ductive health movement.
LYT 98013
120
The changing world
and role of women in society are con- ease is also fairly high as a conse-
sidered. It is estimated that infant quence of postpartum complications
mortality for babies born to this age following infection when childbirth
group could be as much as 80% takes place in unhygienic conditions
higher than for women in the age involving untrained personnel. Little
group 20-29. Adolescents account for information is available about male in-
18% of all women of reproductive age fertility resulting primarily from low
in most of the developing regions of sperm count, often caused by un-
the world and their numbers are ex- treated genital infections. Available
pected to grow worldwide by at least data indicate that primary infertility
60 million between 1995 and 2025. inability to conceive or bear any
Nearly 90% of adolescent women children at all seems low and oc-
aged 15-19 will be in the developing curs among 2-4% of women aged 40-
world by 2025. Adolescent fertility is 44. In the past decade, dramatic ad-
estimated at 66 births per 1000 vances have been made in the inves-
women aged 15-19 years in 1995 tigation and treatment of infertility. Urbanization holds out
worldwide (it is falling compared with
overall fertility rates). It is expected Social trends both a bright promise
to reach 52 births per 1000 adoles-
cent women by 2025, with projected
It is becoming increasingly clear that
births declining by 6% of the number
occurring in 1995 over the course of
health improvements are influenced and a grave threat.
and conditioned by socioeconomic
the next 30 years, mainly due to ris-
factors and developments in such ar-
ing age at marriage, increasing edu-
eas as urbanization, environment, em-
cational and economic opportunities
ployment, education and nutrition,
for young women and increased use
which are major driving forces behind
of contraception.
health trends (Box 22).
Infertility defined as inability
to ensure childbearing when it is
wanted is as much a reproductive Environment and housing
health issue as the inability to avoid
Urbanization has been the essential
childbearing when it is not wanted.
part of most nations development
Infertility affects both men and
towards a stronger and more stable
women of reproductive age. It is es-
economy over the past few decades,
timated that 8-12% of all couples ex-
and it has helped underpin improve-
perience some form of infertility dur-
ments in living standards for a con-
ing their reproductive lives, affecting
siderable proportion of the world
at least 50 million people worldwide.
population. The countries in the
While for a small proportion of cou-
South that urbanized most rapidly in
ples (less than 5%) the underlying
the past 10-20 years are generally also
causes of infertility are attributable to
those with the most rapid economic
anatomical, genetic, endocrinological
growth. Associated with this has also
and immunological factors, problems
been the growth of urban poverty
of infertility in women arise prima-
during the 1980s and early 1990s, and
rily because of untreated infections,
limited successes in improving hous-
frequently linked to pelvic inflamma-
ing and living conditions, including
tory disease. Sexually transmitted dis-
the provision of safe and sufficient
eases, such as gonorrhoea or
water supplies and adequate sanita-
chlamydia, are the most common
tion and drainage. Urbanization thus
source of pelvic inflammatory disease.
holds out both the bright promise of
The risk of pelvic inflammatory dis-
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The World Health Report 1998
an unequalled future and the grave
Box 22. Alcohol and socioeconomic stress threat of unparalleled disaster. Recent
years have witnessed a re-emergence
The period of transition to democracy in the countries of the former USSR of a positive view of urbanization. As
has been associated with a catastrophic increase in mortality. Between 1987 the world approaches the 21st cen-
and 1994 male life expectancy at birth in the Russian Federation fell by over tury with close to 6 billion inhabitants
seven years, to 57.6 years. In some parts of the country, the drop was even and with nearly half this number liv-
greater and life expectancy fell to 49 years, a figure comparable with many ing in urban centres, it is now ac-
parts of sub-Saharan Africa. Life expectancy at birth for women also fell, cepted that a predominantly urban
although to a much smaller extent, resulting in 1994 in a 13-year difference population is not only an inevitable
between men and women the largest sex difference ever documented. part of a wealthy economy, but also
These changes are unprecedented in an industrialized country in peace- one that brings many advantages. The
time. Theories about their cause have included inaccurate data, collapse of challenge is how to manage cities and
the health care system, environmental damage, alcohol and psychosocial other human settlements and ensure
stress. A team of Russian, British and French researchers,using a recon- healthy living conditions in an increas-
structed series of previously unpublished mortality data, has recently shown ingly urbanizing world.
that the trends are real and has accumulated compelling evidence for the About 45% of the worlds popula-
important role of alcohol. tion now live in urban areas and in a
Alcohol consumption has always been a feature of Russian life. In 1985, few years, for the first time in history,
decisive action was taken to address the social consequences of high levels urban dwellers will outnumber those
of alcohol consumption, with a major anti-alcohol campaign, leading to a in the traditionally rural areas as the
dramatic reduction in supply. Within a few years, however, the amount of global urban population increases
alcohol available began to rise again, largely due to illegal production. from 2.6 billion in 1995 to about 4 bil-
The fall in age-specific death rates from a variety of causes after the anti- lion in 2015. The United Nations
alcohol campaign was almost an exact mirror image of the rise after 1989, Centre for Human Settlements
strongly suggesting that the same factors are involved in both. Many of the (UNCHS-Habitat) estimates that by
causes of death affected, such as accidents and violence, alcoholic poisoning the end of the 21st century, more peo-
and pneumonia, have recognized links with alcohol. The one surprise was ple will be in urban areas of the de-
cardiovascular disease, where the prevailing consensus is that moderate veloping world than are alive on the
alcohol consumption is protective. Evidence is emerging, however, that binge planet today. The number of persons
drinking has specific effects on the heart, with a recent Finnish study report- living in urban areas increased glo-
ing a seven-fold increased risk of sudden cardiac death among those drinking bally from 872 million (32% of the
three or more litres of beer at a time. This is consistent with a key finding world population) in 1955 to 1.5 bil-
from the Russian data of a significant increase in sudden cardiovascular lion (38%) in 1975, and to 2.6 billion
deaths at weekends, especially among young and early middle-aged men. (45%) in 1995. It is expected to reach
Other work has shown that a high proportion of Russian men dying suddenly 4 billion (54%) by 2015 (Fig. 16). Al-
have specific evidence of alcoholic damage to their heart muscle. though there is a growing number of
These findings have implications for other countries undergoing social what are termed megacities (with a
and economic transition. They also highlight the importance of considering population exceeding 10 million) they
alcohol as a major cause of premature death in other countries. Alcohol represented only 3% of the world
consumption has been shown to be a major cause of the failure by Hungary population in 1995. New kinds of ur-
to match the gains in life expectancy of neighbouring countries such as Po- ban systems are also developing in
land and the Czech Republic. A better understanding of the linkage between many parts of the world, often around
excessive alcohol consumption, social and economic stresses, and health is the largest cities where a denser net-
likely to be of relevance to some other regions and countries in the world work of smaller cities develop and
undergoing periods of rapid transition. become more dynamic than the large
city itself. While the growth of the
Personal communication from Martin McKee & David Leon, European Centre on Health of
Societies in Transition, London School of Hygiene and Tropical Medicine, United Kingdom.
urban population is faster than over-
all population growth in the develop-
ing world, the annual growth rate de-
clined from 4% during 1955-1975 to
122
The changing world
3.8% during 1975-1995, and is ex- lated to environmental conditions.
pected to decline further and reach Spread via a parasite in freshwater
2.9% per year between 1995 and snails, it infects more than 200 mil-
2015. However, the composition and lion people. Other major vector-
distribution of urban agglomerations borne diseases influenced by environ-
have been changing dramatically dur- mental conditions include lymphatic
ing the past few decades. While the filariasis, dengue fever, leishmaniasis
number of megacities increased from and Chagas disease. Diarrhoeal dis-
one in 1955 to five in 1975, and to 14 eases which are closely associated
in 1995, the number of urban with lack of access to clean water and
agglomerations with a population ex- food, and personal hygiene, cause
ceeding 1 million increased from 90 3 million deaths annually.
in 1955 to 178 in 1975, and to 324 in
1995. There are expected to be 408
in 2015. The proportion of the urban Fig. 16. Urban and rural population, world, 1955-2015
LYT
population living in these 8000
agglomerations has also increased 7000
Urban
from 26% in 1955 to 36% in 1995, and agglomerations
Population (millions)
6000
may be 37% in 2015. This means that > 10 million
5000
a significant proportion of the worlds 1-10 million
urban population live in small mar- 4000
< 1 million
ket towns and administrative centres, 3000
123
The World Health Report 1998
124
The changing world
areas, while sanitation reached 60% example, the acute and long-term
in urban centres and 31% in rural consequences for health of the recent
environments. In developing coun- forest fires in South-East Asia are a
tries, 61% of the population now has case in point of the serious threats to
access to water supply and only 36% health from air pollution on a regional
has access to sanitation. scale. When inhaled, air pollutants
Food is essential to a healthy life, affect the lungs and respiratory tract;
but it can also be a major route of ex- they are also taken up by the blood
posure for many pathogens and toxic and transported throughout the body.
chemicals. These contaminants may And since air pollutants are deposited
be introduced into food during culti- on soil and plants and in water, they
vation, harvesting, processing, stor- can contribute to further human ex-
age, transportation and final prepa- posure if contaminated food and wa-
ration. Biological and chemical agents ter are ingested. Indoor air pollution
in food represent the two major types can be particularly hazardous to
of foodborne hazard. Biological health because it is released in close
agents tend to pose acute hazards proximity to people. The most promi-
with incubation periods of a few hours nent source of indoor air pollution in
to several weeks before the onset of developing countries is household use
disease, whereas chemical hazards of biomass and coal for heating and
usually involve long-term, low-level cooking, usually involving open fires
exposures. or stoves without proper chimneys.
Air pollution, both indoor and Ozone layer depletion due to use
outdoor, leads to an estimated 3 mil- of chlorofluorocarbons has increased
lion premature deaths globally. For rapidly in recent years and the ozone
Fig. 17. Water and sanitation coverage, rural and urban population, 1994 a
LYT 98011
unserved 25 % unserved 65 %
rural urban urban
19% 6% 13%
(836) (589)
(279)
served 75 % rural
12% served 35 %
(505)
a
Percentages relate to global population in rural and urban areas concerned; figures in brackets refer to population in millions.
125
The World Health Report 1998
hole over the South Pole now
Box 23. Climate change Health risks for the 21st century reaches populated areas. A similar
trend is seen around the North Pole
Unprecedented changes taking place in the global climate because of green- and the associated increase of solar
house gas emissions could lead to wide-ranging impacts on human health, UV-radiation exposure may in the
according to some leading scientists. Such climate changes are gradual and next decades cause an increase of
complex, and their environmental consequences are difficult to predict, but cataracts, skin cancer and immune
they could result in marked increases in death and illness from both infec- system damage. The Intergovern-
tious and noninfectious diseases. Various recent scientific studies based on mental Panel on Climate Change has
mathematical models indicate that a global mean temperature increase of concluded that a warming of the
1-2 degrees C would enable mosquitos to extend their range to new geo- Earths surface due to human activi-
graphical areas, leading to increases in cases of malaria and several other ties producing greenhouse gases is
infectious diseases - especially in populations living just outside the areas occurring (Box 23).
where these diseases currently occur. The number and quantities of
The proportion of the worlds population at risk of malaria, presently es- chemicals used, both in developed
timated at 2.4 billion people, could increase from around 45% to 60% by and developing countries, are con-
the year 2050. The estimated number of annual deaths from malaria would stantly increasing. The total number
rise from between the present 2-3 million to 3.5-5 million. There is already of chemicals on the market is now
some evidence that malaria incidence is increasing in a number of highland close to 100 000, while the value of
regions, for example in Kenya, in a manner that is compatible with recent the total global annual production of
regional warming - although other ecological factors may also be involved. chemicals is about $1.5 trillion. The
Dengue, another mosquito-borne disease, currently threatens 1.8 billion population groups most affected by
people. An estimated 50 million people are infected annually, and the dis- chemicals are poor, illiterate people
ease causes about 25 000 deaths. A temperature rise of 1-2 degrees C with little or no access to appropriate
could result in an increase of the at-risk population by several hundred mil- training or basic information on the
lion, with 20 000-30 000 more dengue deaths a year in 2050. A recent risks posed by chemicals to which
study by the World Resources Institute, in conjunction with WHO experts, they are exposed directly or indirectly
predicted that by 2020 - if the current trends in greenhouse gas emission every day. Although both men and
continue - there would be 700 000 avoidable deaths occurring annually be- women are exposed to the health risks
cause of additional exposure to atmospheric particulate matter (PM) pro- related to the use of chemicals in the
duced by the burning of fossil fuels, with 80% of these deaths occurring in rural environment and to chemicals
developing countries. The health effects of PM include cardiovascular and used in cottage industries and in the
respiratory illness. The researchers have calculated that up to 8 million PM- home, womens health can be particu-
related deaths worldwide in the first 20 years of the next century could be larly affected. Infants and children are
prevented by the implementation of a climate policy designed to reduce car- more susceptible to a variety of
bon emissions significantly. They have concluded that regardless of how or chemicals, such as heavy metals and
when greenhouse gases alter climate, reducing them now will save lives several persistent organic pollutants.
worldwide by lessening particulate air pollution, and that the beneficial ef- In favourable circumstances, work
fects of reduced particulate pollution appear to be far greater in rapidly contributes to good health and eco-
developing countries than in developed countries, although they are substan- nomic achievement. With economic
tial in both regions. The study was presented at a United Nations climate development, many countries have
change conference in Kyoto, Japan, in 1997. experienced a shift from the hazards
Some effects of global climate change and stratospheric ozone layer de- that characterized work in agricul-
pletion (a separate but coexistent problem) could be beneficial. For example, ture, mining and other primary indus-
in areas with relatively colder climates, an increase in ambient temperature tries, to those that characterize manu-
could result in a decrease in cardiovascular mortality. But most effects are facturing industries or service indus-
expected to be adverse. For example, stratospheric ozone depletion would tries. Many workers, however, are
increase skin cancer incidence, but scientists calculate that the excess mor- exposed to health hazards that con-
tality involved from increases in skin cancer would be much less than that tribute to respiratory diseases, cancer,
due to the expected rise in malaria deaths from climate change. reproductive disorders, allergies, car-
diovascular disease, psychological
126
The changing world
stress, eye damage and hearing loss,
as well as some communicable dis- Box 24. The health burden of poor housing
eases. New occupational disease
problems have emerged, and the in- Any study of the health burden of poor housing has to consider the health
cidence of reported occupational dis- burden arising not only within the home but also in the area around the
ease has accordingly increased in cer- home. Here are nine features of the housing environment that WHO has
tain developed countries. singled out as having important direct or indirect effects on the health of
Housing is of central importance their occupants:
to quality of life. Ideally, it minimizes The structure of the shelter (which includes consideration of the extent
disease and injury, and contributes to which the shelter protects the occupants from extremes of heat or
much to physical, mental and social cold, insulation against noise and invasion by dust, rain, insects and ro-
well-being. The home environment dents).
should afford protection against the
The extent to which the provision for water supplies is adequate both
hazards to health arising from the
from a qualitative and a quantitative point of view.
physical and social environment. Yet
numerous factors in the home envi- The effectiveness of provision for the disposal (and subsequent manage-
ronment may influence health nega- ment) of excreta and liquid and solid wastes.
tively (Box 24). At least 600 million The quality of the housing site, including the extent to which it is struc-
urban dwellers in Africa, Asia and turally safe for housing and provision is made to protect it from contami-
Latin America live in life- and health- nation (of which provision for drainage is among the most important as-
threatening homes and neighbour- pects).
hoods. Most live in cramped, over- Overcrowding which can lead to household accidents and increased trans-
crowded dwellings with four or more mission of airborne infections such as acute respiratory infectious dis-
persons to a room in tenements, eases, pneumonia and tuberculosis.
cheap boarding houses or shelters The presence of indoor air pollution associated with fuels used for cook-
built on illegally occupied or subdi- ing and/or heating.
vided land. Tens of millions are home-
less and sleep in public or semi-pub- Food safety standards including the extent to which the shelter has
lic spaces for instance pavement adequate provision for storing food to protect it against spoilage and
dwellers and those sleeping in bus contamination.
shelters, train stations or parks. Per- Vectors and hosts of disease associated with the domestic and peri-
haps as many as 600 million also have domestic environment.
inadequate or no access to effective The home as a workplace where the use and storage of toxic or hazard-
health care, which means that the ous chemicals and unsafe equipment may present health hazards.
economic impact of disease or injury
is magnified.
The combustion of raw biomass
products produces hundreds of poverty and on absence of basic
chemical compounds including sus- infrastructure and services gives a
pended particulate matter, such as more realistic picture of urban pov-
carbon monoxide, oxides of nitrogen erty, particularly in the developing
and sulfur. The principal adverse ef- world (as elaborated in The World
fects of these compounds on health Health Report 1997). For a significant
are respiratory, but in poorly venti- proportion of more than 600 million
lated dwellings, especially when fu- people living in life- and health-
els such as charcoal and coal are used threatening homes and neighbour-
to heat rooms in which people sleep, hoods, improvements in levels of
carbon monoxide poisoning is a seri- infrastructure and service provision
ous hazard. and support can be achieved at low
Estimating levels of poverty based cost. UNCHS-Habitat points out that
on poor-quality housing housing such improvements are often with
127
The World Health Report 1998
good possibility of cost recovery. The nity water supply and sanitation by
reason for the very poor housing and the International Drinking Water
living conditions in which a sizeable Supply and Sanitation Decade (1981-
proportion of people live is not that 1990). Recently however, sanitation
they are unable to pay for housing has been given very low priority in
with basic services, but that such comparison to other general develop-
housing is unnecessarily expensive or ment needs, including water supply.
simply not available. Rapid population growth in develop-
The eradication of poverty, par- ing countries, particularly in urban
ticularly housing poverty, is essential areas, has contributed significantly to
for sustainable human settlements the dramatic proportions of the sani-
and thus for sustainable development. tation deficit. For this reason, the
Science and technology have a cru- World Health Assembly will consider
cial role in shaping housing conditions a new strategy on sanitation for high-
and living and working environments, risk communities in 1998.
Investing in peoples and in sustaining ecosystems. Qual- The Earth Summit held in Rio de
ity of life depends on the indoor and Janeiro, Brazil, in 1992 heralded a
outdoor conditions and spatial char- new approach to national and inter-
health and their acteristics of villages, towns and cit- national development and environ-
ies. However, it is imperative that ment planning. World leaders recog-
governments recognize their role as nized the importance of investing in
environment is a active agents in building an enabling improvements to peoples health and
environment for applying knowledge their environment as a prerequisite
prerequisite for and experience in these areas for sus- for sustainable development. Con-
tainable human settlement develop- tinuing commitment to securing hu-
ment. The challenge is for society to man health and a healthy environ-
sustainable be willing to meet these needs and ment is now widespread, as evidenced
for governments to formulate inno- by a number of declarations and state-
vative policies and programmes for ments that have emanated from re-
development. action to make our human settle- cent international conferences.
ments safe and liveable. A plan to this WHOs Commission on health and
end was elaborated at the United environment provided a substantive
Nations Conference on Human Set- input into the preparation of Agenda
tlements (Habitat V), held in Istan- 21, the blueprint for action towards
bul in 1996. human-centred sustainable develop-
ment, and WHOs global strategy on
WHOs response health and environment was devel-
oped as a response. As part of the fol-
From 1950 to 1970, WHO empha- low-up process, a worldwide effort is
sized environmental sanitation. In under way to prepare national plans
1971, the Fifth general programme for sustainable development. Confer-
of work noted that a dark side of in- ences of health and environment min-
dustrialization and urbanization was istries convened by WHO in the
the emergence of factors detrimen- Americas, Eastern Mediterranean
tal to health, e.g. pollution, road acci- and Europe have been instrumental
dents and stressful city life, and that in accelerating the process, and agree-
the previous concept of environmen- ments have been reached on dead-
tal sanitation had evolved into that of lines for completing such plans. For
environmental health. During the example, in Europe, by the end of
1980s, considerable impetus was 1997 more than 50% of all countries
given to the improvement of commu- had prepared national environmen-
128
The changing world
tal health action plans. Following international concern
In 1997, WHO published Health about the dangers posed by chemi-
and environment in sustainable devel- cals to humanity and the environment
opment: five years after the Earth expressed by the United Nations
Summit, which brings together quan- Conference on the Human Environ-
titative data on health-and-environ- ment in 1972, the International Pro-
ment issues with examples from re- gramme on Chemical Safety (IPCS)
gions and countries. Other publica- was established in 1980 as a collabo-
tions include Linkage methods for rative programme of WHO, ILO and
environment and health analysis UNEP. During the past two decades,
technical guidelines, which, together IPCS has made full evaluations of
with its companion volume, the Gen- some 200 chemicals. Guidance has
eral guidelines, was used in teaching been provided on safe levels of some
workshops on epidemiology for deci- 100 chemicals in drinking-water, 35
sion-making. Other activities have chemicals in air, 655 pesticides and
contributed to further strengthening 30 veterinary drug residues in food, WHO is coordinating
the international and national systems and of 1205 food additives. Guidance
for radiation emergency medical pre- has also been provided on diagnosis
paredness and response, the medical and treatment of toxic exposures to research into possible
and epidemiological monitoring of some 250 chemicals, and on the safe
populations affected by the use of 1300 chemicals in the
Chernobyl accident, and the under- workplace. In 1993, IPCS initiated a
associations between
standing of biological and health ef- project to globally harmonize ap-
fects of low-dose radiation. proaches used by different countries electromagnetic fields
In response to growing public for the assessment of risk. IPCS is-
health concerns in Member States, sues, on a biannual basis, a CD-ROM
WHO is coordinating and encourag- containing the various published out- and a number
ing research into possible associations puts of the chemical programmes of
between low-frequency electromag- WHO and its partners. International
netic fields and a number of diseases organizations are also cooperating of diseases.
such as childhood leukaemia, breast with IPCS to develop a global infor-
cancer, and diseases of the central mation network on chemicals, and to
nervous system. In 1997, the repre- provide information electronically,
sentatives of 31 agencies from 17 with access through the Internet.
countries identified the most impor- Twelve environmental health cri-
tant gaps in the existing scientific teria monographs were published in
knowledge. This has enabled WHO 1997. These are comprehensive docu-
to make recommendations to the in- ments which provide internationally
ternational scientific community con- peer-reviewed assessments of risk to
cerning research priorities in this field human health and the environment
over the next four years. from exposure to chemicals. The
A sanitation promotion kit was IPCS chemical incidents project pro-
developed in 1997 as the foundation vides guidance to the health sector on
of a new WHO strategy on sanitation. preparedness for and response to di-
Country workshops and hygiene edu- rect or indirect exposure of
cation seminars were held in all re- populations. A harmonized format for
gions to promote sanitation as a ma- international exchange of data on
jor instrument to reduce diarrhoeal chemical incidents is currently being
mortality in infants. A comprehensive field-tested with the assistance of a
guidebook was issued on the manage- WHO collaborating centre (Univer-
ment of health care wastes. sity of Wales Institute, Cardiff).
129
The World Health Report 1998
Major investment in international progress since the beginning of the
work will have to be made if the goal 1970s, when the number of persons
of evaluating a further 500 chemicals with inadequate access to food was
by the year 2000, as requested by the about 920 million. In relative terms
UN Conference on Environment and it declined from 35% of the popula-
Development, is to be met. Research tion in the developing world to 21%,
is also needed to better elucidate the primarily as a result of progress in
etiology of diseases caused by chemi- East Asia (including China) and parts
cals, including those which may be of South Asia, such as India and Pa-
caused by endocrine-disrupting kistan. Worldwide average daily per
chemicals, as well as other impacts of capita dietary energy supply increased
chemicals on the health of vulnerable from less than 2300 calories in 1961-
population groups, particularly 1963 to 2440 in 1969-1971, to 2720
women, children and the elderly. in 1990-1992 and is expected to reach
a value of 2900 calories by 2010. The
In almost all countries Food and nutrition population with an average dietary
energy supply per capita per day of
Food security, defined as the ac- more than 2700 calories increased
there are people cess for all people at all times to from 145 million in 1969-1971 to
enough food for an active and healthy more than 1.8 billion in 1990-1992
life, underpins the food for all ini- and is expected to be 2.7 billion by
who suffer from tiative launched at the World Food 2010.
Summit in 1996. Much of the work For several developing countries,
hunger and in this area was concerned mainly the 1970s was a decade of improve-
with food security and until recently ment, faster than that of the 1960s,
focused on the adequacy (or inad- with rapid progress continuing up to
malnutrition. equacy) of food availability to meet about the mid-1980s but at a slower
the nutritional needs of the popula- pace thereafter. However, several
tion. countries and even whole regions
In almost all countries there are failed to make progress and even ex-
people who suffer from hunger and perienced outright reversals. The
malnutrition a pathological state situation is most serious in Africa,
resulting from too little consumption where the number of classically un-
of essential nutrients but the extent dernourished people in sub-Saharan
and the pattern differ substantially countries more than doubled during
from country to country. One way to this period. Even though the global
examine the nutrition situation and average may increase to 2800 calories
monitor developments in world food per day by 2010, there may not be sig-
security is to look at the food supply nificant nutrition progress. The popu-
available for consumption. Average lation with inadequate access to food
dietary energy supply in calories de- may decline only from 840 million to
rived from national food balance 680 million, although this would rep-
sheets and population data show that, resent a reduction from the present
although enough food is supplied glo- 21% of the population of the devel-
bally, at least 840 million people in oping countries to 12% in 2010.
the developing world had inadequate The green revolution which began
access to food in the early 1990s (i.e. in the 1960s has been seen as a glo-
below the nutrition threshold that bal technological achievement, the
represents a minimum level of energy effects of which are still being felt
requirements). This figure, though today. Innovative approaches focus-
high, reflects a substantial degree of ing on economic, social and environ-
130
The changing world
mental factors that affect the food supply measurements assume that
production process should also be available food is distributed and con-
addressed, however. To this end FAO sumed in relation to requirements,
proposes urban agriculture as a which is rarely the case. Several meas-
possible solution to the concerns re- urements of the human body directly
lated to food insecurity in the next related to intake have therefore been
25 years.. Urban agriculture is de- developed. Childrens body measure-
fined as food production that occurs ments, for example, are particularly
within the confines of cities, for ex- sensitive to changes in the intake of
ample in backyards, community veg- protein and calories as well as to the
etable gardens or unused spaces, and onset of disease. Protein-energy mal-
is mostly small-scale and scattered. nutrition (PEM), generally referred
City farming has a long tradition in to simply as malnutrition, is an im-
many societies, especially in Asia and balance between the supply of pro-
Europe. The contribution of urban tein and energy and the bodys de-
agriculture to food security (defined mand for them to ensure optimal
as the holding of a certain supply of growth and function. Such an imbal-
food to be available and accessible at ance leads to wasting, stunting and
all times) appears to be substantial in underweight when energy intake is
many developing cities. 200 million inadequate, and to overweight and
urban farmers worldwide supply food obesity when it is excessive (Fig. 18).
to 700 million people, or about 12% The most commonly used indica-
of the world population. Surveys have tor of PEM is the percentage of chil-
shown for example that urban farm- dren whose weight-for-age falls below
ing provides 50% of vegetable con- a reference value (international
sumption in Karachi and 85% in growth curves) usually set by WHO
Shanghai. Women form the bulk of and the United States National
producers in both Africa and Latin Center for Health Statistics. Under-
America. weight prevalence in children under
Nutritional status of the popu- 5 has declined in developing coun-
lation depends on food consumption tries, from 46% in 1975 to 31% in
and not solely on production and 1995, but progress has not been uni-
availability of food. Dietary energy form. Recent WHO estimates suggest
Fig. 18. Percentage of population underweight and overweight, selected countries, around 1993
Underweight Overweight
(Body Mass Index <18.5) (Body Mass Index >25)
Russian Federation
United Kingdom
Sweden
Colombia
Brazil
Costa Rica
Morocco
Togo
China
Haiti
Senegal
LYT 98005
Ethiopia
India
60 50 40 30 20 10 0 0 10 20 30 40 50 60
Percentage of population Source : WHO
131
The World Health Report 1998
that worldwide in 1995, 168 million lion) among children under 5 years
children under 5 were classified as by 2025. For adults, even the most
underweight (31% of the total). In optimistic trend gives a global value
developing countries, about 206 mil- for 2025 of 82 million for severely
lion (38%) were stunted, and about underweight and 131 million for
49 million (9%) wasted. The risk of moderately underweight; severe over-
being malnourished as measured by weight prevalence in 2025 is esti-
underweight is 1.2 times higher in mated at 300 million adults. Growth
Asia than in Africa, and 3 times higher in the number of severely overweight
in Africa than in Latin America. The adults is expected to be double that
number of under-5s living in each of underweight adults during 1995-
geographical area 54 million in 2025. In order to assess the implica-
Latin America, 121 million in Africa, tions of these trends for the future
and 363 million in Asia renders the health of mankind, the following fig-
distribution among regions even ures should be considered: excess
Growth in the number more unequal. South-central Asia has adult mortality in 1995 attributable to
by far the highest malnutrition levels, undernutrition is estimated at about
both in terms of prevalence rates and 0.5 million deaths and to overnutri-
of severely absolute numbers. In this subregion tion at about 1 million; mortality rates
alone, about 50% of under-5s (86 mil- increase by about 25% and 100% re-
lion) are malnourished, accounting spectively in underweight and over-
overweight adults for half the total number of malnour- weight persons.
ished children in developing coun- Prevalence of micronutrient mal-
is expected tries. nutrition in respect of iron, iodine and
Mortality rates in children under vitamin A is more widespread than
5 are 2.5 times higher in those that PEM (Table 9). An estimated 2 bil-
to be double that of are moderately underweight, and lion people are anaemic, with nearly
5 times higher in the severely under- 3.6 billion iron-deficient. Anaemia
weight. About 50% of deaths among prevalence is highest (around 50%)
underweight adults. these children were associated with in pregnant women and preschool-
malnutrition, while for about 300 000 age children in developing countries.
under-5 deaths in developing coun- Iodine deficiency disorders affect
tries, malnutrition was the direct about 15% of the worlds population,
cause. It is also estimated that about 834 million having goitre, 16.5 million
22 million children under 5 years are cretinism. Vitamin A deficiency (sub-
overweight. WHO estimates that in clinical) affects about 285 million
developing countries about 245 mil- (42%) of under-5 children globally;
lion adults are moderately under- about 0.5% are severely affected
weight and 93 million severely un- (xerophthalmia). Iodine deficiency
derweight. At the same time, there disorders are declining rapidly how-
are over 200 million adults who are ever, thanks to near-universal salt io-
moderately or severely overweight, dization. Sustainable elimination by
of whom 58 million are in develop- 2000 or 2010 is possible. Clinical
ing countries. Overall it appears that vitamin A deficiency could with sus-
in any country developed or devel- tained effort be eliminated by 2025.
oping prevalence of malnutrition The main problem is in dealing with
(underweight and overweight) is iron deficiency, but with widespread
about 50%. iron fortification programmes, slow
WHO estimates that underweight reduction would be possible.
prevalence in developing countries
should decline to about 28% (165 mil-
132
The changing world
133
The World Health Report 1998
The worldwide adult literacy rate in- mulated in the context of rapid
creased from 70% of the population changes in economic conditions and
aged 15 years and over in 1980 to 78% in the quantity and quality of labour.
in 1995, and it is expected to reach Since the 1970s, changes in the
about 83% in 2010 (Fig. 19). While technology and organization of pro-
progress is narrowing the gender gap, duction in the developed economies
striking disparities between males and and a slower rate of productivity and
females and among countries still per- real output growth have made the
sist. While increased enrolments of achievement of low unemployment in
children in formal schooling are cru- a non-inflationary environment much
cial, masses of illiterate and poorly- more difficult than had been antici-
educated adults are still inadequately pated, and certainly much more dif-
prepared as parents, workers and citi- ficult than it appeared to be 50 years
zens in the emerging global society. ago. At that time, the Universal Dec-
Improvements in literacy rates have laration of Human Rights provided
Over 120 million been more pronounced among the for the right of individuals to produc-
younger age group. Both developed tive employment, and many devel-
and developing countries are there- oped economies adopted policies
people worldwide fore paying more attention to the ba- aimed at achieving full employment,
sic education of adults. Nonformal or or at least high levels of employment.
out-of-school education is increas- Over 120 million people world-
are officially ingly seen as a necessary component wide are officially unemployed and
of a comprehensive strategy to pro- many more underemployed, causing
unemployed. vide education for all. massive personal suffering, increased
poverty, marginalization, exclusion,
Unemployment inequalities, reduced well-being, loss
of dignity, widespread social disinte-
The International Labour Organiza- gration and huge economic waste.
tion (ILO) estimated the world labour The ILO considers an individual to
force at about 2.7 billion in 1995, with be unemployed if he or she is cur-
78% in developing countries. As a rently without employment, is ac-
result of both demographic factors tively seeking employment and is
and behavioural changes, developing available for employment within
countries share in the total world la- some time period mutually accept-
bour force is expected to continue to able to both the prospective employee
increase, reaching 81% by 2010 (2.8 and a prospective employer. In many
billion), but the average annual rate developing countries, unemployment
of growth is expected to slow from remains a major unresolved problem
2.2% (over the period 1950-1995) to and there has been a rise in under-
1.9% over the next 15 years, with vari- employment, with a majority of the
ations among countries. labour force remaining in low-pro-
While the world economy contin- ductivity work that offers no escape
ues to absorb the bulk of a rapidly ris- from poverty. In a majority of indus-
ing global workforce, which is better trialized countries, unemployment
educated, possesses greater skills and has persisted for over two decades
is more mobile than at any time in the while most transition economies have
past, unemployment has emerged as experienced a rapid rise in unemploy-
a problem and the effectiveness of ment since 1990.
labour markets has become a policy Youth unemployment is a seri-
issue. Approaches to solving the prob- ous problem in several developing
lem of unemployment are being for- countries, where at least 20% of male
134
The changing world
LYT 98014
Illiterates, female Illiterates, male Literates, both sexes
a
Percentage of total adult population; figures in brackets refer to the number of literates and illiterates in millions.
Source: UNESCO.
youth aged 20-24 years are unem- rise the pattern of growth must be
ployed. The relative share of people labour-absorptive, and this in turn is
seeking their first job, the majority of determined in part by the quality and
whom are young workers and women, quantity of labour. Lack of employ-
within the total unemployed popula- ment opportunities among the high-
tion has been increasing over the past est skilled labour and educated pro-
decade. Economies in many regions, fessionals are pushing them to leave
particularly in Africa, have not been their country in search of work abroad
able to absorb new labour market a phenomenon known as the brain
entrants. drain.
Economic restructuring in many The problems of unemployment,
countries has contributed to reduc- underemployment and poverty are
ing demand for educated labour, severe in the developing world. The
particularly where the public sector majority of the labour force remains
used to represent the main source of trapped in low-productivity employ-
demand for such skills. Growth alone ment in the rural and informal sec-
is no guarantee that employment will tors which offer little relief from pov-
135
The World Health Report 1998
erty. On average, unemployment in Asia incomes had risen by more than
the industrialized countries is also 60% of the 1970 level, while in East
much higher now than it was in1950- Asia (including China) 1995 per
1970. It is 50% higher in the United capita incomes were more than twice
States and about seven times higher the 1970 levels. The countries that
in Germany than in the 1960s. With saw a decline in their per capita in-
the increasing integration of the world comes over the period constituted
economy, issues of employment and about 12.5% of the total population
labour standards have assumed a glo- of developing countries in 1990, most
bal dimension, since trade and invest- of these being low-income countries.
ment flows have become an increas- About a quarter of the world popula-
ingly important influence on domes- tion lives in dire poverty and in many
tic employment prospects and policy regions it is increasing. There is also
options. The scope for national policy a widening gap between the living
autonomy is restricted and the effec- standards of this quarter and those of
With the increasing tiveness of traditional policy instru- the more privileged who enjoy rising
ments reduced, particularly in labour standards of living. There is, however,
and social policy. an increasing international commit-
integration of the ment to ensure that the poor share
Poverty the benefits of economic expansion
and social development, and in many
world economy, Although there have been setbacks countries special attention is now be-
and difficulties, the global economic ing paid to those living in absolute
issues of employment expansion of recent decades has poverty and those who are disadvan-
brought great economic and social taged as a result of discrimination,
progress to many areas of the world. age, disability or infirmity (Box 25).
and labour standards Mass poverty has been eliminated in Both the absolute poor and the
the economically more advanced non-poor are trapped in a situation
countries and significantly reduced in where economic growth and social
have assumed many developing countries. Meas- development are interdependent.
ured in constant terms, incomes per Low incomes mean limited capacity
capita in 1995 were about 90% higher to save and invest, limited means for
a global dimension. in the developing countries than they obtaining health services, high risk of
were in 1970. The figure for the de- personal illness, limitations on mobil-
veloped countries was about 60%. ity, and limited access to education,
Infant mortality rates have fallen and information and training. Poor par-
life expectancy has risen. There have ents cannot provide their children
been advances in education, health with the opportunities for better
care, living conditions and technology. health and education to improve their
However, this prosperity has not lot. Lack of motivation, hope and in-
been universal. Economic growth has centives creates a barrier to growth,
been slow or non-existent in many and poverty is passed from one gen-
poorer countries. Recent estimates by eration to the next. To rise out of pov-
the World Bank of the number of erty, the poor need the enhanced op-
people living below a common global portunities provided by faster eco-
poverty line indicates that in West nomic growth as well as improved
Asia and sub-Saharan Africa per ability to respond to the opportuni-
capita incomes had fallen to 80-90% ties available.
of their 1970 level, in North Africa The central goal of development
and Latin America incomes had risen is increasingly recognized as the
by 25-50% of the 1970 levels, in South strengthening of human resources so
136
The changing world
The World Health Report 1995 Bridging the gaps drew are fully compatible with the principles of sustainable hu-
attention to the widening gap between the health of privi- man development. Both rely on participatory techniques
leged and underprivileged groups and concluded that pov- applied to local communities at risk. Both are closely linked
erty is the worlds deadliest disease. Noting that health to environmental concerns and adopt people-centred strat-
and socioeconomic development are inextricably linked, egies. Both acknowledge that the best help is self-help,
the report also presented compelling arguments for fo- and both aim to achieve community self-reliance through
cusing on the needs of vulnerable groups as a strategy decentralized and integrated multisectoral approaches.
for achieving sustainable human development. The Mediterranean Centre for Vulnerability Reduction
The practical relevance of this strategy was demon- was created to serve as a regionwide technical institu-
strated in late 1997, when WHO inaugurated the Medi- tion and centre of reference and excellence for the Medi-
terranean Centre for Vulnerability Reduction and thus for- terranean basin. The Centres primary concern is to de-
mally launched a new approach to the prevention and man- velop the technical approaches and programmes needed
agement of major risks in vulnerable groups. The approach to help communities at risk to strengthen their own ca-
recognizes that certain communities are at chronic risk pacity for vulnerability reduction and risk management.
of emergencies due to factors that range from geographi- The scope of activity includes the following types of
cal location and climate, through the proximity of dams, risks:
industry, and other technological hazards, to poverty and epidemics caused by infectious diseases;
the social exclusion it imposes. technological risks, including chemical and radiologi-
While some of these factors cannot be altered, com- cal hazards;
munities can nonetheless be helped to protect themselves, natural risks, such as floods, earthquakes, cyclones,
to cope and recover, and thus to prevent risks from turn- and landslides;
ing into emergencies, and emergencies into disasters. societal risks, such as those caused by social exclu-
The approach aims, in short, to stop the downward spiral sion and extreme poverty.
of adverse event, emergency relief, dependance, with- Tunisia, which provides the Centres premises and infra-
drawal of short-term aid, deterioration of conditions, in- structure, has close links to the concept of vulnerability
creased vulnerability, emergencies, and recurrence of dis- reduction and nationwide experience in its practical appli-
aster, with even worse results. cation. In recent years, the entire Tunisian population has
Although comparatively new, vulnerability reduction is mobilized support for a wide-ranging initiative aimed at
firmly rooted in what WHO, the United Nations Develop- fighting poverty and eradicating social exclusion by the
ment Programme, and other development agencies have year 2000. In the view of the government, such a pro-
learned about the dangers of fragmented sectoral assist- gramme, accompanied by broad popular support, repre-
ance and the advantages of seeking long-term results. sents the surest strategy for preventing social instabil-
The approach draws on strategies that are known to ity, which so often has its roots in inequalities, social ex-
work. Efforts to reduce vulnerability and to manage risks clusion, and extreme poverty.
137
The World Health Report 1998
come. The connection between edu- an elimination of the manifestations
cation, health and earning capacity of poverty.
is better understood. Policies are be- National strategies for combating
ing formulated to prepare the un- absolute poverty should include a
skilled for better jobs, augment the modernization process that could ac-
supply of scarce skills, upgrade the celerate and sustain long-term growth
training of the poor, improve the of labour productivity and enhance
functioning of the labour markets individuals health and knowledge
and improve the health status of the potential to contribute to society. To
population of working age. For the ensure that workers output and earn-
full benefits of such policies to be ings increase, the labour force must
reaped by the poor, a major effort be better educated and more adapt-
may be needed to upgrade schools, able and be supported by improved
clinics, sanitation and other public technology and management, all of
services. which require investment in human
The connection Recent evidence suggests that and physical capital.
raising literacy levels and reducing Above all, good governance the
mortality and ill-health rates is more rule of law, equity, participation by all
between education, difficult for countries with a lower in society and the provision of efficient
level of GNP per capita. Even so, basic services is essential if growth is
policy interventions have been to take place rapidly and provide maxi-
health and earning launched to increase literacy and sur- mum benefit for the poor. At the com-
vival prospects, even at low levels of munity level, implementation of pov-
capacity is better per capita income. Raising incomes erty programmes should be in support
through faster economic growth, of the activities carried out by local and
combined with appropriate social self-governing institutions and should
understood. development policies, has contrib- facilitate local involvement to raise
uted to a decline in poverty in the productivity and the material condi-
world and even in some regions, to tions of the poor.
138
Achieving health for all
Chapter 5
Achieving health for all
I
n 1997, 158 Member States drugs. On average, only 50% of pa-
(representing 91% of the global tients take their medicines cor-
population) reported to WHO rectly, and up to 75% of antibiot-
the findings of an evaluation of ics are prescribed inappropriately,
progress in the implementation of the even in teaching hospitals.
strategy for health for all in their Findings show that substantial,
countries. Based on data and infor- though only partial, progress has been
Overall survival mation provided by these reports, made in achieving the goals of the
supplemented from international global strategy for health for all. Over-
sources, WHO estimates that: all survival prospects of the popula-
prospects of the In 1995, 102 Member States, with tion worldwide have improved, but
a total population of 3.4 billion disparities in health levels between
(60% of the global population) had and within countries have persisted
population worldwide reached at least the minimum life and in many cases increased. In spite
expectancy at birth of above 60 of political commitment by Member
years; infant mortality rate of be- States and the development of health
have improved, low 50 per 1000 live births; and systems based on primary health care,
under-5 mortality rate of below 70 issues of inequalities in health status
but disparities in per 1000 live births. and health care access seem not to
Immunization coverage of infants have been adequately or effectively
in 1996 was nearly 90% for BCG addressed during the past two dec-
health levels have and about 80% for DPT3, measles ades. The stage has been set however
and poliomyelitis. For tetanus tox- for developing and sustaining health
oid, however, coverage of pregnant systems that are dynamic, effective
in many cases women was below 50% of live and able to meet changing health care
births in developing countries. needs.
In the developing world in 1996, More details are given in this
increased. coverage for antenatal care was chapter, which can be supplemented
65% of live births; for deliveries in by reports prepared in each WHO
health facilities, 40%; and for region for the third evaluation of the
skilled attendance at delivery, 53%. implementation of the global strategy
About 90% of newborns weighed for health for all, and reviewed by the
at least 2500 g at birth, and the respective regional committees in
available limited data show an in- 1997.
crease in infant care coverage since
1986. Health for all and
In 1994, at least 75% of the popu-
139
The World Health Report 1998
assessed the global health situation. of physicians. Moreover, ordinary
Reports on the world health situation people had little control over their
were used to convey salient findings own health care, as health profession-
and main problems and achievements als were rarely willing to trust them
to the World Health Assembly. Table to make decisions about their own
10 gives selected extracts from the health.
first eight reports on the world health In 1977, the World Health Assem-
situation spanning from 1954 to 1989. bly reaffirmed that health is a basic
The Fifth report, covering the period human right and a worldwide social
1969-1972, underlined in particular goal, that it is essential to the satis-
the slow progress in improving the faction of basic human needs and
health status of developing countries, quality of life, and that it is to be at-
and the widening gap in health status tained by all people. The Assembly
and access to health care between and called for the vigorous transformation
within countries. The report alerted of existing health care strategies to
There was a realistic the global community through the facilitate the attainment of health for
World Health Assembly to the con- all as defined in the Constitution of
tinuing inability of health services to WHO, and decided that the main so-
expectation that reach out to those in dire need and to cial target of governments and of
provide, on a permanent basis, access WHO should be the attainment by all
to health care for the entire popula- the people of the world by the year
by the year 2000 tion at a price that they could afford. 2000 of a level of health that would
Over 5 million children were dying permit them to lead a socially and
no country, or annually of diarrhoea, and more than economically productive life. In other
half of all child deaths could be traced words, as a minimum, all people in
to malnutrition, and diarrhoeal and all countries should have at least such
no individual citizen, respiratory diseases. Failure to con- a level of health that they are capable
trol such diseases of poverty pre- of working productively and of par-
vented further reductions in mortal- ticipating actively in the social life of
should have a level ity rates, and in incidence rates of the community in which they live.
major diseases such as malaria, schis- There was a realistic expectation
tosomiasis, filariasis, cholera and lep- that by the year 2000 no country, or
of health below an rosy which had even increased. no individual citizen, should have a
level of health below an acceptable
acceptable minimum. The imperative for change minimum, and that the world com-
munity would later adopt a new strat-
Too few resources were being in- egy to take people further towards the
vested in the health sector, and these goal of health for all in the future. The
were usually spent on meeting the target date of 2000 was intended as a
needs of 10-15% of the population. challenge to all Member States. If this
Richer countries had been attracting initiative was successful, the next in-
doctors from the poorer ones over termediate target would be to achieve
three-quarters of the worlds migrant further improvements in health be-
physicians were to be found in only yond the year 2000, with a better
five countries: Australia, Canada, quality of life for all people, taking
Germany, the United Kingdom and into account changes in the demo-
the United States. Although the train- graphic, socioeconomic, environmen-
ing of a physician was eight times tal and epidemiological situation.
more expensive than that of a medi-
cal auxiliary, many developing coun-
tries were still stressing the training
140
Achieving health for all
141
The World Health Report 1998 Table 10. World health as assessed in the Repor
The World Health Report 1998
Socioeconomic development Health system
Degree of incompleteness varied considerably between different diseases, countries and parts of the
problems same countries and from one period to another (notification of communicable diseases).
Main
Two parallel and more or less disconnected systems of medical and health services greater
attention to medical side.
Report 1
1954-56
Modern concept of health as a state of physical, mental and social well-being and not merely the absence of disease
achievements
Peoples awareness for their own participation to build up the health of the nation.
Effort to improve the quality of human life adding life to years.
Realization that health cannot be imposed: its promotion requires teamwork within the community.
problems
Main
Report 2
1957-60
There had been scientific, economic and political changes, from 1959 to
achievements problems achievements
Understanding that the problem of health must be based on precise information and precision implies
1960 which positively influenced health development. measurement.
Main
Political changes, independence, enough freedom of thought and action Work on establishment of indicators which would mark definitely the signs of improvement and
and of association in the councils of the world. achievements in health matters.
The great boom of education in some developing countries.
Main
Report 3
1961-64
Express desire to organize health planning as a part of total planning for socioeconomic development.
Establishment of central bodies for health research in the countries.
problems
Main
achievements
health.
achievements problems
Main
% of GNP spent on health in developing countries, 2-3% (a few US$ per capita expenditure).
80% of adult population illiterate in low-income countries.
Report 6
1973-77
achievements
30th World Health Assembly in 1977: Health-for-all strategy primary health care.
Main
1000 million people living in absolute poverty, 90% of whom in rural areas. Some factors affected the evaluation process: not yet suitable methods, no definite baseline for
Main
GDP per capita had fallen especially in Latin America and Caribbean. measuring, lack of information support to managerial process.
Report 7
1978-84
Illiteracy of adults from 48% in 1970 to 40% in 1980. Endorsement of health-for-all strategy from almost all countries.
Positive trends in mobilizing communities for health and allocation of resources.
Disparities between the least developed and other developing countries Slow progress due to slow reorientation of disease control programme towards peoples needs, difficult-
problems
had increased. ies in involving all those concerned with health, weak management of health care delivery system etc.
Main
Degradation of living conditions in developing countries, especially in urban National health expenditure devoted to local health services had decreased in least developed countries.
Report 8
1985-89
areas. In 1/4 African countries per capita expenditure on health was under US$ 5.
achievements
Slight increase in % of GNP spent by national governments for health in developing countries.
Per capita GNP some increase in developed countries. Increasing number of countries adopted policy of decentralization and delegation of responsibility to
Main
Adult literacy rate increased from 62% in 1985 to 66% in 1991. district level.
People increasingly involved in improving their own health.
142
rt on the World Health Situation, from 1954 to 1989 Achieving health for all
Achieving health for all
Health status Health services
Very high infant mortality rate and maternal mortality rate in developing countries. Very low vaccination coverage (no exact data).
Half of the children died before they reached the age of five years. Water supply and waste disposal systems quite inefficient.
Disease problems: malaria, 1.5 million deaths, smallpox still a menace. Great shortage of water supply and sanitation in larger cities: 10-30% of dwellings without these
Prevalence (millions): trachoma 400, malaria 150, yaws 50, onchocerciasis 20, leprosy 12. facilities.
General trends towards the improvement of health status (decline in increase in height and weight Application of some simple technology (chlorination, fluoridation, long-acting penicillin, etc.).
and improvement in nutritional status). Dental health services had been expanding rapidly in many countries.
Still very high infant mortality rate and maternal mortality rate in developing countries.
Preventive and curative medicine are not easily integrated (antithesis between preventive and
Half of the children died before reaching the age of five years. curative medicine).
Rate of poplation growth of 3% and more per annum in some countries. Antisocial concentration of medicine and nursing skills in the larger cities.
Increase in number of venereal diseases, mental disorders and anxiety states and accidents.
Increase in life expectancy at birth, highest values in Europe and the Americas.
Some diseases show withdrawal rapid decrease in number (smallpox in the Americas since
April 1971 last case in Brazil, cholera fewer notified cases, etc.).
Treatment of some diseases effective: plague, tuberculosis, yaws, etc.
No improvement in some diseases/conditions: diabetes, acute respiratory infection, malaria, Low % of children immunized less than 10%.
malnutrition, accidents, maternal mortality (developing countries), etc. Inadequate distribution of manpower: urban/rural.
Food and nutrition, 1000 million globally without enough food. % of population with access to safe drinking-water not satisfactory in rural areas in developing
Annual increase of global population: 80 million. countries.
Infant mortality rate decreasing in developed (8.3-40.3/1000 live births) and in developing
(130-200/1000) countries. Contraceptive methods slow increase.
Life expectancy at birth increasing (male: 53.9 years, female: 56.6). Number of medical schools increase.
Population over 65 increased. Smallpox no new areas. Drinking-water supply improved in urban areas.
Endemic treponematoses low prevalence. Drug control laboratories established in some countries.
Mortality from cardiovascular and ischaemic heart disease decrease in some developed countries.
Infant mortality rate still high: over 50/1000 live births in 79 countries. Immunization coverage (DTP-3rd dose low 15%)
Mortality from ischaemic heart disease increased in under 65s in most countries. Some improvements in water supply and sanitation nullified by population growth and drought.
143
The World Health Report 1998
The political nature of health, ill- Managing progress
ness and health care.
The value of representative de-
in implementation
mocracies in all countries where To ensure that governments and
human, political and socioeco- WHO know whether they are mak-
nomic rights are truly respected. ing progress with the implementation
The inextricable play of econom-
of their strategies and whether these
ics, religion and culture with poli- strategies are effective in addressing
tics in decision-making and prior- the health concerns and improving
ity-setting in health. the health status of the people, the
The value of peace and conflict
Organizations Member States agreed
resolution as essential conditions at the World Health Assembly in 1981
for physical, mental and spiritual to monitor progress and evaluate the
health. effectiveness of their strategies at
The value of institutional designs
Experience of the past regular intervals, and to report their
that ensure government capacity to findings to the WHO governing bod-
manage political struggles where ies. Implementation was monitored
the results affect peoples well-
20 years shows being negatively.
in 1983, 1988 and 1994, and evalu-
ated in 1985, 1991 and 1997. The
The essential importance of gov-
findings were then reviewed by the
ernance in managing transitions,
that governance is one crises and new paradigms.
regional committees and by the
World Health Assembly.
The implications of politics and
The process and progress in health
of the decisive factors policy-making for WHOs techni- systems development and the trends
cal cooperation in the future: po- in health care coverage during the last
litical contexts should be moni- two decades are highlighted below.
in securing the tored in a systematic way so as to
be able to foresee some possible
impacts on health development;
Health systems devel-
implementation of and to support ministries of health opment
and other partners in the formula-
tion of better health policies. Up to 1978, the biomedical model of
primary health Experience of the past 20 years shows health systems predominated, and the
that governance is one of the decisive health sector was confused with the
factors in securing the implementa- medical sector. To develop a health sys-
care goals. tion of primary health care goals. It is tem, doctors and nurses were trained,
also essential to strengthen the social, hospitals established, infrastructures
political and psychological capacity of created and medicines distributed, es-
people to facilitate the shifts in val- pecially in towns and for populations
ues and behaviours required to par- that could afford them. Access to mod-
ticipate and be active in decision- ern health care was extremely limited
making. Trust in the systems of jus- in many developing countries, particu-
tice, protection and security must be larly for rural populations. The limita-
secured. Transparent assignment of tions of the biomedical model were
resources, financial execution and evident. Fortunately, following the
social participation in the process of Declaration of Alma-Ata in 1978, new
decision-making are also part of good channels and alternative experiments
governance. opened up increasingly credible op-
tions worldwide.
144
Achieving health for all
The three main elements of the Resources for health
strategy (which went far beyond the
prevailing biomedical model) were: Countries can be divided into three
the development of peripheral serv- groups according to the predominant
ices, an intersectoral approach and method of financing their health sys-
community participation. The strat- tem: mainly based on taxation; chiefly
egy was adopted, more or less explic- based on social insurance; character-
itly, by the vast majority of countries. ized by centrally-planned normative
Changes in the economic and po- distribution of government budget
litical situation in the 1980s proved funds. With a significant increase in
to be a major obstacle to the imple- most countries in the role of the pri-
mentation of the health-for-all strat- vate sector in the delivery of services,
egy. It was adopted several years too both equity and allocation issues are
late for the political and social move- receiving more attention. Concerns
ments that could have provided sup- have also been raised about the qual-
port and served as a springboard for ity of care. With a significant
development. So, before long, it was In all countries, the reform proc-
criticized, distorted, taken over and ess is bedeviled by the growing costs
interpreted more and more restric- of health services. The ageing of the increase in the role
tively. In general, however, the results population, associated with an in-
of the health-for-all strategy have creased need for health care, the
been encouraging as regards the de- availability of new treatments and
of the private sector
velopment of peripheral health serv- technologies and rising public expec-
ices, but little has been done to pro- tations, all exert financial pressures. in the delivery of
mote an intersectoral approach and Most countries are responding with
community participation. a series of measures to control rising
WHO continued to support the costs. In western Europe, for exam- services, both equity
principles of health for all, but organ- ple, successful macroeconomic meas-
ized itself in such a way as to deal with ures have given way to additional ef-
prevalent diseases in developing forts to restrain escalating costs at the and allocation issues
countries. It pushed the medical ap- institutional level. In the countries in
proach as far as it could go, even in transition, this approach has been less
prevention, by giving greater empha- successful, although there is some are receiving
sis to vaccinations and vertical pro- evidence of improving efficiency. The
grammes. quest for cost-containment and more
Appropriate preventive, curative efficiency, and the imperative to iden- more attention.
and community care has a central role tify more resources, frequently take
in the pursuit of the health-for-all tar- precedence over the health-for-all
gets. Using adequate policy instru- principles and values. Consequently,
ments and cost-effective manage- from the patients point of view, of-
ment of resources, appropriate care ten what is referred to as reform
focuses on accessible primary care, does not contain any elements of im-
supported by strong secondary and provement. Patients are asked to pay
tertiary care, including services for more and receive less.
people with special needs, in order A core concern in countries en-
to ensure a high quality of care, and gaged in reforming their funding sys-
maximum health gains. tem is to balance the principle of soli-
darity with pressures to establish com-
petition among insurers and provid-
ers. Private health insurance schemes
are often operated in a manner that
145
The World Health Report 1998
corrodes social solidarity. On the allocated to health has failed to in-
whole, the western European coun- crease, or has even diminished. There
tries decided to retain their general is still a gross imbalance between ex-
health care policy orientation as be- penditure on tertiary care and ex-
fore, but they have made major penditure for local care, to the detri-
changes. More choice, competition ment of the latter. Progress in this
and pluralism have been introduced area has been marginal.
in tax-based systems. Insurance- In general, reliable and valid data
based countries are paying more at- on health care financing are sparse in
tention to cost containment, primary most developing countries. In addi-
health care and preventive services. tion, data on expenditures in the pri-
In other regions, countries where the vate sector are often difficult to ob-
tax-based systems are deemed to be tain. Yet in most countries of South-
insufficient are reviewing the option East Asia, for example, 60-75% of the
of health insurance; for example, the total health expenditure occurs in the
The proportion Philippines has adopted an expanded private sector. Direct out-of-pocket
comprehensive national insurance spending by households appears to
system, although the need to subsi- account for a major portion of private
of the GNP allocated dize the poorer segments of society spending in most countries in the
is limiting its success. In the Eastern Eastern Mediterranean, while private
Mediterranean, growth of health ex- insurance premiums account for a
to health has failed penditure since 1990 has been rather limited fraction of private spending.
slow, partly because of the difficult This means that households bear a
to increase, or has economic environment prevailing substantial proportion of health care
since the mid-1980s and the conse- costs while having little or no finan-
quences of the structural adjustment cial protection (i.e. insurance) in the
even diminished. programmes in several developing event of major illness or injury.
economies of the Region. Several In many developing countries,
countries have tried to mobilize the additional resources for the health
necessary funds through alternative sector are provided by nongovern-
financing schemes based on cost- mental organizations and bilateral
sharing and the development of and international donors. The role
health insurance schemes. played by nongovernmental organi-
A central issue for many countries, zations in both the provision and fi-
such as China, is improved coordina- nancing of health services is grow-
tion and management of multiple ing in many countries as a conse-
funding sources. Many health systems quence of diminishing resources in
struggle to keep up with rising costs public sectors. As the prospects of
or are affected by national decisions financial assistance from many do-
to reduce expenditure on health. Vari- nor countries are not optimistic,
ous cost recovery mechanisms are owing to economic recession and
therefore being explored. Malaysia cuts in developing assistance pro-
and Mongolia are investigating user grammes, financial institutions are
charges to finance certain health serv- being approached for loans aimed at
ices, although possibly not critical supporting health development pro-
care services. grammes. In many less developed
In Africa, investment in health has states, external sources of funding
virtually ceased. The social sectors, support disease control activities and
including the health sector, have been critical health promotion services,
hardest hit by the worsening budget such as campaigns related to mater-
deficits. The proportion of the GNP nal and child health and immuniza-
146
Achieving health for all
tion. In these countries aid coordi- to health care. This aspect is further
nation remains a concern. worsened by privatization policies. An
Few countries, even the most important share of recurrent budgets
prosperous, are satisfied with the of ministries of health is allocated for
distribution of financial resources tertiary care, thus limiting resources
between promotive and curative for primary health care services, and
services. preventive and promotive pro-
In Europe, redistribution of finan- grammes. On average, 43% of na-
cial resources towards primary health tional health expenditure is devoted
care could not be confirmed by the to local health care, down from 50%
few existing data. Some evidence in the early 1980s.
about the outcome of such reform Experience in some countries has
policies comes from other indicators, shown, however, that decentralization
such as immunization rates and infant may also have negative effects such
and perinatal mortality, which mostly as fragmented services, or inequity.
improved, although this was not con- Successful decentralization requires Successful
sistent. Disparities in access between sufficient local administrative and
social groups also persist, and in some managerial capacity and appropriate
cases have even worsened. mechanisms for accountability and decentralization
In the Western Pacific most coun- citizens participation. In addition,
tries devote sufficient resources to the there is evidence that certain areas
health sector and thus express their such as the basic framework for health
requires local
priority concerns in terms of issues of policy, or regulations concerning pub-
equity, appropriate allocation of the lic safety, are better managed cen- administrative and
resources and efficiency. This has trally. Decentralization of responsibil-
become an important issue for China, ity for primary health care to local
where central funds are used to bal- authorities is not always accompanied managerial capacity
ance regional and rural funds. by a shift of financial resources. In
Malaysia, for example, recognizes that Europe, for example, the reluctance
the public system should ensure that of hospital-based medical specialists and mechanisms for
appropriate social safety nets are in to accept policies that strengthen pri-
place for those who, for economic mary health care and/or restrict di-
reasons, have difficulty accessing ap- rect access to secondary care are a accountability and
propriate care. In most countries of continuing feature. Services are still
the Region, basic care of children, often characterized by the existence
older citizens and those with other of parallel vertical programmes. In- citizens participation.
special needs is met by governments. tegrated horizontal services are nev-
In Cambodia and the Lao Peoples ertheless being developed in some
Democratic Republic, however, the European countries, providing a full
allocation to the health sector is 2% range of outpatient services supple-
or less of the gross national product, mented by home care, in cooperation
and is not sufficient to meet basic with the social welfare services.
needs. Problems associated with human
Data from some countries in the resources vary in different regions.
Eastern Mediterranean show that In the Americas, the expansion of
public resources are not equally dis- human resources has in particular
tributed between geographical re- been limited by recent cutbacks in
gions and between social classes. spending by the public sector, precipi-
They tend to favour urban and well- tated by the downturn in the
off populations and to generate po- economy. Another factor has been
larization with regard to accessibility high management turnover because
147
The World Health Report 1998
of changes in government and direc- and will need to be encouraged and
tion and the lack of a personnel policy expanded since they have proved
and of appropriate incentives to mo- their effectiveness in some cases.
tivate personnel. In the Eastern Mediterranean,
In South-East Asia, on the other although human resources have been
hand, the absolute and relative num- produced and deployed in larger
bers of most categories of health per- numbers, their distribution is not bal-
sonnel have risen. Most countries are anced among the different levels of
examining their personnel policies care, nor is it always equitable within
and formulating plans; expanding and countries, or balanced between vari-
strengthening the capacities of edu- ous categories. Some countries (e.g.
cation and training institutions; and Lebanon and Pakistan) have more
updating and reorienting the cur- physicians than nursing/midwifery
ricula to meet the changing needs of personnel because of cultural or em-
the health services. Countries con- ployment factors, or shortages in edu-
Most countries tinue to make use of other training cation and training facilities. There
resources in the Region to supplement are problems of absorbing graduates
their own training opportunities. (e.g. in the Islamic Republic of Iran),
are examining their Investment in human resources and of low intake of nationals in nurs-
for health has been such that in most ing institutes, for cultural reasons.
countries in the Eastern Mediterra- The recruitment and deployment of
personnel policies; nean Region, the resources allocated health personnel may be carried out
for personnel consume 60-70% of the by a central government body irre-
strengthening total budget of ministries of health. spective of real needs, and rapid
Recent demographic and epidemio- progress in technology and increased
logical changes have resulted in an public awareness of needs may also
the capacities of increase in the overall ratios of hu- be causing pressure. Health person-
man resources for health, especially nel are concentrated in the capital or
nursing and midwifery personnel. other cities, where university hospi-
training institutions; This can be attributed to the in- tals and other secondary and tertiary
creased number of nursing institutes care institutions exist. This disparity
and increased demand, and is the fewer physicians assigned to pri-
and reorienting the outcome of health policies launched mary health care despite more physi-
several years ago. Measures adopted cians joining the services raises sev-
include incentives to work in remote eral issues. In addition to the factors
curricula to meet the and rural areas (e.g. in Iraq), and the mentioned above, primary health care
involvement of nongovernmental or- may not be attractive for physicians
ganizations in training health person- when it is remote and without incen-
changing needs of nel (e.g. in the Islamic Republic of tives.
Iran). Examples in other regions include
In many African countries, the low the Philippines, where the output of
the health services. output of health institutions and poor educational institutions does not
performance of health personnel re- match what the service needs. Among
main major concerns. The brain drain its many health initiatives, New Zea-
continues, undermining the public land is attempting to address this is-
sectors capacity to respond to health sue with specific purchasing agree-
needs. The phenomenon of unem- ments for educational institutions. Sin-
ployment among school leavers is gapore has recognized the need to sup-
particularly affecting the health sec- port the training of nurses in order to
tor. Although some initiatives have address similar concerns. China is ex-
been taken, they are of limited scope ploring market mechanisms to meet
148
Achieving health for all
health service needs encouraging In Europe, the implementation of
practitioners to run their own clinics policies to develop primary health
or consultations, and encouraging care is accompanied by the introduc-
healthy competition between medical tion of schemes for training general
institutions to improve efficiency and practitioners/family physicians, or for
reduce costs, thus matching demand the retraining of physicians already in
for care at different levels. practice. Some countries are devel-
In the Americas, the most impor- oping family physician services with
tant constraint is the failure to develop a parallel community nursing service,
a model of human resource needs in where one did not already exist. Also
health in coordination with training there is a tendency to create aca-
institutions, and the trend towards pro- demic departments of general prac-
fessional medical specialization per- tice/family medicine and to introduce
sists, with a steady rise in the number the subject into the undergraduate
of physicians. The health workforce curriculum of medical students.
continues to be largely female and con- Most countries in South-East Asia There is a
centrated in nursing. Reduced em- have also taken steps to increase pro-
ployment in health and the changes in duction of certain categories of health
financing resulting from state reform personnel, including voluntary work- tendency to create
have influenced policies related to the ers, in order to improve and expand
development of new human resources coverage, especially at the community
for health in most countries. At the level. A few have established new cat-
academic departments
same time there are no signs that the egories of personnel and new train-
geographical and social distribution of ing programmes in an effort to meet of general
health workers has improved; they re- increasing and changing health serv-
main highly concentrated in the cit- ice needs. For example, Maldives is
ies, to the detriment of rural areas and now conducting a diploma course in practice/family
urban peripheries. Virtually all coun- primary health care to train middle-
tries are aware of the urgent need to level managers and Myanmar has
rectify this situation. The appearance established a new institute which of- medicine and to
of new factors in the health sector job fers a degree in community health to
market (banks, NGOs, other agencies) prepare public health officers in
has meant significant changes in the charge of basic health services in pe- introduce the subject
mechanisms and processes involved in ripheral areas. There is, however, a
the regulation of health care and the tendency of educational institutions
health professions. Meanwhile, how- to seek quality in the abstract, with into the undergraduate
ever, structural action needed for solv- insufficient attention to the real needs
ing the problem is often postponed or of the communities and their limited
considered unviable. resources. Deficiencies in training fa- curriculum of
In the Western Pacific, the main cilities, teaching capability and re-
strategy is continually to upgrade the sources are also constraints.
skills of the workforce through edu- In the Americas, on the other
medical students.
cation and training, with particular hand, countries usually have a vari-
emphasis on continuing education. ety of institutions that, working in iso-
Upgrading is seen as a particularly lation, make decisions about training
important issue in China. Cambodia and education needs. The institutions
is revitalizing its health system responsible for training human re-
through a national continuing educa- sources have tended to neglect edu-
tion programme. Continuing educa- cation in public health, health policy,
tion is an explicit priority in Kiribati and health management.
and the Philippines.
149
The World Health Report 1998
In Africa, many countries made lishing, equipping and maintaining
the development of infrastructure the health infrastructure in some
the focus of their health policy, but countries. Most countries have given
the results obtained were uneven in priority to upgrading the health infra-
view of limited investment capacity. structure, particularly in rural areas.
Hospitals continue to consume the Remote health facilities are often
largest share of the health budget, linked by telecommunications. Im-
sometimes at the expense of health proving the infrastructure is often
centres. Maintenance of facilities and hampered by staffing difficulties and
equipment is inadequate, not only shortage of spare parts. Moreover,
because of financial constraints but improvements may not systematically
also for cultural reasons. Quite often, benefit poorer populations. Nepal, Sri
achievements could not be sustained Lanka and Thailand have compre-
without international cooperation. hensive networks of health facilities
In the Americas, in contrast to the extending to the village level. Access
Hospitals continue 1970s, infrastructure development to primary health care has been con-
policy in the past 15 years has stag- siderably improved, and work is now
nated and is currently one of the com- being undertaken to ensure planned
to consume the ponents with the greatest need for development and maintenance. As-
support. Generally, health policy does sistance from international funding
not provide for the development of agencies has also been very useful in
largest share of physical infrastructure such as facili- that respect.
ties and equipment. This means that In the Eastern Mediterranean,
the health budget, equipment is not procured on the initiatives have recently been taken
basis of an evaluation of the health to ensure equitable distribution of the
needs of the population. In the ma- infrastructure. Many countries have
sometimes at jority of countries, technical services opted to specify catchment areas as
are not an integral part of the health the unit for planning health services,
care system, nor are maintenance and in general physical infrastructure
the expense of plans for hospital equipment. Equip- has received considerable attention
ment is not utilized because it is in- and investment, often benefiting from
appropriate, because of lack of per- bilateral and multilateral assistance
health centres. sonnel who know how to use it, or projects. Construction and renovation
because of minor faults and a lack of of secondary and tertiary hospitals has
spare parts. In addition, ministries of also developed, but at a slower rate.
health generally do not have a suffi- Accessibility to health services
cient budget for repairing and main- reached 82% in 1990 and has been
taining infrastructure and equipment, sustained. Further expansion of cov-
so that international assistance is of- erage has been hampered by civil
ten the only recourse. strife in some countries and by the
The physical infrastructure in high cost in remote areas. Outreach
many South-East Asian countries has and mobile teams are used as alter-
continued to expand, particularly at natives to static units to serve scat-
the primary and first referral levels. tered and remote populations. Linked
Health care facilities in the private to accessibility are two other param-
sector have expanded, as reflected by eters, coverage and utilization. The
the increasing number of private hos- reported pattern of utilization varies
pital beds. However, maintenance of among and within countries.
infrastructure appears to be a prob- Underutilization is sometimes due to
lem in many countries, and commu- a lack of availability of budgetary re-
nities are becoming involved in estab- sources for drugs, physicians, health
150
Achieving health for all
staff and equipment or to the avail- of hospital beds per 1000 population
ability of alternative acceptable serv- has decreased in all parts of the Re-
ices, whether provided by traditional, gion, most notably in some countries
private or nongovernmental organi- of eastern Europe. On the whole,
zations. Facilities constructed thanks however, the costs of hospital treat-
to donations from nongovernmental ment have probably increased, both
organizations or communities or in absolute terms and as a proportion
through loans are often not included of total health expenditure. Progress
in proposals for recurrent budgets has been made regarding alternatives
due to poor coordination between to hospitalization such as day surgery,
planning and financial departments. day care and home care.
Public facilities buildings, equip- Increasingly, countries in all re-
ment and supplies are not usually gions are endeavouring to ensure
well maintained, because of lack of quality of care, through the identi-
financial resources and qualified per- fication and constructive use of best
sonnel. Few countries have adequate practices and the optimal use of ex- Countries in all regions
repair and maintenance workshops, isting resources. In 1993, the Euro-
whether centralized or decentralized. pean Forum for Medical Associations
Some countries contract out for main- stated that ensuring quality of care is are endeavouring
tenance and repair of biomedical an ethical, educational and profes-
equipment. Underuse of equipment sional responsibility inherent in the
may result from poor maintenance or medical professions. Good progress
to ensure quality
from shortage of necessary supplies is being made in European countries
such as chemicals. Ministries of following the achievement of consen- of care, through
health cannot compete with private sus on quality indicators, e.g. for dia-
firms in attracting scarce qualified betes management and obstetrical
repair and maintenance technicians. and perinatal care. Outcomes in cen- constructive use
There is a need for resources to be tral European countries have been
provided through bilateral and mul- identical to those in western Europe,
tilateral cooperation in this area. while at the same time quality of care of best practices
Since hospitals are the main con- has been achieved with less frequent
sumers of health care resources, they use of technology-intensive interven-
have been at the centre of health care tions. and the optimal
reform in every European country. In the Americas, although some
There have been many changes countries have set up a classification
aimed at increasing patient satisfac- system to define the levels of poten- use of existing
tion, rationalizing resources and tial risk to the health of the popula-
achieving better outcomes. Most tion, based on quality and safety cri-
countries claim moderate to good teria, greater organization is still resources.
development in this area, although needed for its use in practice. In one
the pace of change has been slower country for example, only 0.8% of the
than desired. The number of hospi- facilities evaluated had some method
tal admissions has varied widely, even for treating hazardous solid waste.
between countries with similar levels In the Eastern Mediterranean,
of economic and health development. countries have undertaken assess-
Hospitalization all over Europe has ment of health services to identify
shifted further from chronic and sim- new entry points to improve perform-
ple surgical procedures to acute, day ance. Some countries (e.g. Bahrain,
hospitals and shorter length of stay, Egypt, Jordan, Morocco) have initi-
and complicated pathologies and ated quality control programmes at
treatments. On average, the number selected levels of care. Capacity-
151
The World Health Report 1998
building and training of health per- most can be satisfactorily treated
sonnel in techniques and methodolo- through adequate primary care, sup-
gies of quality of care continue. ported by appropriate technology,
Many countries are turning to and by people themselves through
community participation as a part guided self-care.
of the action needed to reinvigorate Major difficulties in the function-
the strategy for health for all, e.g. ing of health care facilities are: the
Bahrain, Egypt, Oman and Sudan. lack of specific definitions of promo-
Other examples include Mongolia, tive, preventive, curative, rehabilita-
which is redirecting services by mak- tive and supportive functions for each
ing use of a new type of family- level of care; the uneven distribution
oriented practitioner, and Cook Is- of health care facilities; the absence
lands, Samoa and Vanuatu, where of regional networks with proper re-
nurse/community practitioner pro- ferral links; the lack of appropriately
grammes are being pursued. In In- trained personnel, its maldistribution
Many countries are dia, community participation is being and the inappropriate combination of
encouraged for the procurement of education and specialization; insuffi-
medical equipment for hospitals, and cient management training; and the
turning to community cost-sharing schemes have been in- lack of simple low-cost material and
troduced for the maintenance of methods designed for, and adapted to,
health facilities. For improving drug local conditions.
participation as a part accessibility and affordability, com- Conventional health care delivery
munity cost-sharing schemes are be- systems, as developed in some afflu-
of the action needed ing implemented in Indonesia, ent countries, are unlikely to provide
Myanmar, Nepal and Thailand. Some a suitable model for other countries
communities are also participating in because the solutions they imply are
to reinvigorate the procurement of equipment. too costly and, therefore, irrelevant.
The aim is to achieve a proper bal-
Health care coverage ance between need and supply, cen-
the strategy for tralization and decentralization, and
costs and effects, and greater flexibil-
Health care delivery systems ity of the whole system of health care
health for all. The objective of a comprehensive
delivery, including referral.
In integrated health services all
health care delivery system is to pro-
service units in a geographical area
vide services to deal with existing
form a functional unit. The trend is
health problems through the best uti-
to extend the range of the service unit
lization of available resources. Na-
to the periphery. In the more afflu-
tional health care delivery systems are
ent countries where chronic condi-
measured against four criteria: impact
tions prevail, high priority should be
on the health problems of the popu-
given to integrating acute care in a
lation; coverage of the population in
general hospital with the functions of
relation to the resources allocated;
outpatient care and institutions for
efficiency of services in attaining the
extended care. In the developing
objectives at minimum possible cost;
countries, where infectious condi-
and the effectiveness of activities that
tions prevail, the emphasis should be
are health-related, though not carried
on the integration of preventive pro-
out by the health services. As a rule,
grammes in existing or developing
only a small number of patients re-
health care services. Integrated dis-
quire the intervention of highly spe-
ease control should be part of the de-
cialized medical care services, and
velopment process.
152
Achieving health for all
Since 1981, the trend has been Health education
towards improvement in health care
coverage as a result of the following In the late 1970s health education
factors: the extent of government, units were set up in many countries
political and social commitment to throughout the world, but policy de-
achieving health for all; the commit- velopment was not a priority. Activi-
ment of financial resources for health ties focused mainly on information-
by governments and the mobilization giving and on campaigns around life-
of resources by individuals and com- style-related issues in the developed
munities; growing management capa- world, and infectious diseases in de-
bilities for programme implementa- veloping countries. Starting in 1986,
tion among health personnel and at the five action areas of the Ottawa
community level. In general, health Charter for Health Promotion (healthy
personnel are being better trained public policy, supportive environ-
and oriented to communicating and ments, community action, personal
working more effectively with their skills and reorienting health services) Greater emphasis
peers, with government, with other set the agenda for health promotion.
sectors, and with individuals and com- Follow-up conferences in Adelaide
munities. (1988) and in Sundsvall (1991) elabo- is given to the
But many problems still remain. rated the concept further and devel-
The percentage of the population oped a more holistic and intersectoral
covered with essential services has approach to promoting and protecting development of healthy
increased, but millions of people re- health, particularly in developed coun-
tries. Greater emphasis was given to a
main without access to water and
settings approach to health such as, for
public policies
sanitation services and to the basic
elements of care because the in- example, the development of healthy
creases in the services available have cities, health-promoting schools, is- backed up by the
not kept pace with the increases in lands, municipalities and villages, hos-
population. The gap between the pitals and workplaces. Gradually a
availability of different elements of more decentralized approach to health necessary legislation
health care in developed countries education and health promotion de-
and in the least developed countries veloped, with subregions or provinces
is widening, although there are gen- taking over responsibilities from na- and resources.
eral improvements, even in the poor- tional institutions. Health promotion
est group of countries. There are also with its emphasis on intersectoral ac-
wide gaps within countries, between tion and settings provided the frame-
rich and poor and even between dif- work within which health education
ferent areas within countries, often remained an important component.
exacerbated by the economic decline Developments in communications
of the 1980s and 1990s. Services are technology revolutionized the poten-
often fragmented and coordination tial for health promotion. Meanwhile,
between the public and private sectors increasingly greater emphasis is given
and with nongovernmental organiza- to the development of healthy public
tions needs improvement. The qual- policies backed up by the necessary
ity of care is generally high in most legislation and resources.
developed countries, although the
overavailability of drugs and of tech- Nutrition
nology can lead to other problems.
One-fifth of the population of devel-
oping countries does not have access
to enough food to meet basic needs.
153
The World Health Report 1998
Low-income countries with a food were 31% in 1985 and 53% in 1990.
deficit continue to face declining food There are great differences between
production and complex emergencies and within countries, particularly be-
that have displaced massive numbers tween urban and rural areas. From
of people, (see Chapter 4). The preva- 1990 to 1994 the number of people
lence of protein-energy malnutrition without sanitation increased by nearly
in children under 5 in developing 300 million, totalling almost 3 billion
countries declined from at least 42% for developing countries in 1994 (see
in 1975 to over 31% in 1996, indicat- Fig. 17). This figure is projected to
ing that in general dietary protein had increase to over 3 billion by the year
become widely available. Anaemia, 2000. From 1990 to 1994 nearly 800
mostly due to iron deficiency, was the million people gained access to safe
most common nutritional deficiency water supplies but, due to population
worldwide in the 1970s and remains growth, the number of unserved de-
so. Over the past 20 years there has creased only from 1.6 billion in 1990
Public policies been some decrease in the prevalence to 1.1 billion in 1994. The rural popu-
of iodine deficiency disorders, par- lation remains at a disadvantage: in
ticularly in recent years following 1994, sanitation coverage in rural ar-
aimed at creating near-universal salt iodization by 1995 eas was a mere 18% whereas it was
in most countries affected. Vitamin A 63% in urban areas; access to water
deficiency is decreasing worldwide, amounted to 70% in rural areas and
a healthy environment but severe forms are still common in 82% in urban areas.
parts of sub-Saharan Africa. There are positive developments
are becoming more Foodborne illnesses continue to be a however. The focus is shifting from
major public health concern in both drinking-water quality alone towards
developed and developing countries. overall improvement of the environ-
generally accepted. ment. Public policies aimed at creat-
Water supply and sanitation ing a healthy environment are becom-
ing more generally accepted.
In 1972, the United Nations Confer-
ence on the Human Environment Maternal and child health
brought environmental concerns to
global attention for the first time. In The range of health care needs that
the mid-1970s there were approxi- can arise during and just after preg-
mately 3 billion people in the devel- nancy make the challenge of ensur-
oping world, only 38% of whom had ing the access of all women to relevant
safe drinking-water and 32% ad- services complex. Current global es-
equate sanitation. In 1978 the Inter- timates show that in the developing
national Drinking-Water Supply and world approximately 65% of pregnant
Sanitation Decade was launched with women receive at least one antenatal
the stated goal of clean water and ad- visit during pregnancy; 40% of de-
equate sanitation for all by the year liveries take place in health facilities;
1990. and slightly more than half of all de-
In 1980, safe water supply was liveries are assisted by skilled person-
available to about 50% of the world nel. This contrasts sharply with de-
population, while adequate sanitation veloped countries, where practically
was available to about 35%. In 1985, every woman receives regular care
an average of 55% of the populations during pregnancy, delivery and the
in developing countries had safe wa- postpartum period.
ter. By 1990 the figure had risen to Postpartum care has been a rela-
66%. The figures for excreta disposal tively neglected aspect of maternity
154
Achieving health for all
care. It does not feature in the goals
set at major international conferences Box 26. WHOs Expanded Programme on Immunization (EPI)
and the lack of reporting is an indica-
tion of low priority. Less than one-third One of the most dramatic current goals for EPI is the eradication of poliomyelitis
of developing countries report national by the year 2000. While there are still difficulties in raising the resources needed
data, and levels of coverage can be as to ensure that the job is finished on time, all the indications are that progress
low as 5%. Estimates based on the lim- towards the goal is on target. Reported BCG and DTP3 coverages have re-
ited data available indicate a coverage mained steady since 1990 at about 90% and 80%, respectively. Countries in
of 35% at the global level. This low greatest need have reported a slow, but steady improvement for DTP3 cover-
level of care is disturbing, since timely age, increasing from 26% in 1988 to 44% in 1996. At least 86 countries have
interventions during the postpartum now introduced hepatitis B vaccine into their routine immunization programme,
period can prevent deaths of both and at least 25 have introduced Haemophilus influenzae type B (Hib) vaccine.
mothers and newborn infants, and can The managerial process of immunization programmes has particular fea-
reduce the incidence of long-term tures which differ from those of other programmes. EPI has strongly recom-
pregnancy-related illnesses. mended that annual operational plans be developed looking at all managerial
In developed market economies aspects of health. Such activities have provided a good basis for measuring
and economies in transition, well over programme effectiveness.
90% of pregnant women received EPI has been instrumental in establishing links between partners in im-
antenatal care in 1996. Deliveries took munization, enhancing the use of funds in ways which support other parts of
place in health facilities and were at- the health sector as well as immunization.
tended by skilled personnel. In the EPI has focused attention on countries in greatest need those requiring
least developed countries, while nearly technical and financial support. Such countries have low national programme
50% receive antenatal care, only 30% implementation capacity and have received little support compared to other
deliver in health facilities or have countries which are financially and technically stronger. Support for immuni-
skilled attendants. In other develop- zation in the area of, for instance, training has resulted in improvements in
ing countries the numbers are around other areas of health care.
70% and 60% respectively. Worldwide, For a long time, surveillance has been regarded as an unwelcome neces-
only every third woman receives care sity for immunization programmes, and not carried out well. Through the
from a skilled health professional in the polio eradication initiative, the entire surveillance system has been revital-
postpartum period. Estimates of anae- ized to the extent that many countries now report polio data weekly. In addi-
mia in pregnancy are less than 20% in tion, an effort has been made to include other infectious diseases in the
developed market economies and same reporting system, e.g. yellow fever, dengue and meningitis.
economies in transition, but are above A basic requirement for all national immunization programmes is an intact
50% elsewhere. and functional cold chain. This facility is useful for many other primary health
In 1965, only about 9% of all mar- care products not used by EPI. Stock control training for management of vaccines
ried women of reproductive age in also facilitates the management of other commodities used in health centres.
developing countries, or their part- EPI promotes safe injections for immunization and for all other purposes.
ners, were using a method of contra- EPI has developed auto-destruct syringes which can be used only once be-
ception. Today this figure is approach- fore they block and have to be disposed of. The method of disposal of any
ing 60% worldwide. However, the fer- autodestruct or disposable syringe and needle is important, and EPI has
tility-regulating needs of large seg- developed and promoted the use of safe boxes which successfully dispose
ments of the world population remain of them and prevent these sharp items from contaminating the environment.
unmet by the currently available While vitamin A is not a vaccine, the target group of infants and mothers
methods and services. is the same, at least in countries where the vitamin deficiency exists. By
These indicators of maternal giving the inexpensive vitamin orally at the same time as immunizations, the
health care utilization have a number cost for both commodities is reduced.
of limitations. They do not, for exam- The most devastating illnesses (including measles) of children living in
ple, reflect the content or quality of developing countries is dealt with by the strategy of integrated management
the care provided. of childhood illnesses. By supporting this initiative, EPI has helped to pro-
Just as maternal health is depend- duce a comprehensive teaching programme for training health care workers.
ent on many factors, newborn and
155
The World Health Report 1998
Immunization
In the early 1980s there were three
a concerns with regard to immuniza-
B. Reported incidence, 1997
tion: immunization levels were low;
supplies of vaccines and infrastruc-
ture for their dissemination were in-
adequate; and the immunizable dis-
eases were limited primarily to diph-
theria, pertussis, tetanus, polio, mea-
sles and tuberculosis.
The Expanded Programme on
Immunization was established in
1974 and immunization service deliv-
ery was rapidly improved by staff
training; the development of secure
Reported number
Certified polio free cold chains; and the availability of
0 cases routine immunization. Success was
110 cases
>10 cases WHO 98137
measured by vaccine coverage levels,
a
Data as of February 1998. No data available and successful reduction in the inci-
Data for the African Region relate to 19961997.
dence of some diseases through wide-
spread immunization made it possi-
ble to consider the elimination of dis-
eases such as measles and neonatal
tetanus, or even the eradication of
Global polio immunization coverage, 1980-1996 some diseases such as poliomyelitis
Infants immunized
20 33
0 2000. Map 9 shows reported inci-
1980 1985 1990 1995 1996 dence in 1987 and 1997.
Year
Global policies and strategies for
immunization have been adopted by
156
Achieving health for all
virtually all countries of the world. Fig. 20. Unimmunized infants, 1980-1996 a
LYT 98022
Overall immunization rates against
the six vaccine-preventable childhood
diseases have increased from less than
50% in 1980 to over 80% worldwide
in 1995. 59
56 80
Neonatal tetanus is now a target 80 64
for elimination with a possibility of 60
60 69
success by 2000. A time-frame for the 49
Percentage
global elimination of measles will be 40 54 40
20
set by the year 2000. The vaccine for 21 20
20 20
hepatitis B has been added to the 19 21
21
standard list, as has the vaccine for 0
20
19 19 0
21
yellow fever in endemic areas. Mean- 12 19
20
16 19
while, some 20% of the worlds chil- 1980
1985
13
20
15
dren, most of whom are among the 1990
1991 13
13 ine
poorest and least privileged, continue 1992 13 cc
1993 Va
to be unreached by immunization Year 1994
1995
(Fig. 20). Some countries, even some 1996
from less than 20% in the early 1980s tive interventions are developed
to more than 60% in the mid-1990s. and promoted for disease clusters
In the developing countries, where to ensure optimal impact on health
neonatal tetanus remains a major status and make better use of re-
157
The World Health Report 1998
sources. Examples of this approach Capacity at national and global lev-
are the Expanded Programme on els is reinforced to recognize and
Immunization which aims to con- respond rapidly and effectively to
trol six major childhood diseases outbreaks of emerging and re-
through immunization; the Inte- emerging diseases. For example,
grated Management of Childhood mechanisms are being established
Illness that focuses on five major by WHO for a global surveillance
childhood killers; and the recent system supported by a team of ex-
move towards integrating activities perts who can be at the location of
for the control of clusters of tropi- an outbreak anywhere in the world
cal diseases (Box 27). within 24 hours of being officially
notified.
158
Achieving health for all
Africa, access to drugs is still inequi- Map 10. Populations with regular access to essential drugs
table even though it has been im- A. 1987 estimates
proved by introducing cost recovery
as part of the Bamako Initiative and
other similar initiatives (Map 10).
In the Americas, drug legislation
and regulation have constituted a pri-
ority component of health sector
referm in many countries the ob-
jective being to create and/or update
the legal framework to improve the
supply and rational use of drugs.
Three major problems have been
identified with respect to public poli-
Proportion of population
cies on essential drugs: the annual >95%
budget is low in terms of the need for 8195%
5080%
coverage; the supply is ineffective; <50% WHO 98062
159
The World Health Report 1998
logical disease patterns. In many WHOs response
countries, donor support from inter-
national agencies is making a signifi- Strengthening national health admin-
cant impact on the availability of istrations has been one of the major
good-quality essential drugs. Tax ex- objectives of WHO since its creation.
emption for the importation of essen- Starting in 1950, WHO has advocated
tial drugs and the introduction of ge- the integration of specialized health
neric drug policies and price regula- service activities in a general health
tions in general, and for essential programme. The focus was on
drugs in particular, is facilitating ac- strengthening local health services,
cess to essential drugs in many coun- integrating mass campaigns against
tries. In addition, the increasing in- specific diseases into general health
volvement of the private sector in the services, carrying out research on
provision of health services including public health practices, and provid-
drugs is making essential drugs more ing essential preventive and curative
WHOs Ninth accessible to all citizens in several health facilities to all the population,
countries that have introduced cost- especially in remoter districts where
sharing mechanisms. Public health health services are often non-existent.
general programme services are focusing more on the sec- In 1962, the World Health Assembly
tions of the population who are less considered that the creation of a net-
able to fend for themselves, while work of minimum basic services must
of work placed wealthier people use the services of be regarded as an essential pre-invest-
the private sector. Availability has im- ment operation, without which agri-
integrating health proved, and eight out of 10 countries cultural and industrial development
in the Region produce essential would be hazardous, slow and uneco-
drugs. nomical. In 1965, WHO outlined two
and human Although European countries possible approaches for integrating
spend up to 30% of health care funds mass campaigns into the general
on medicines, in all countries there health services: sequential campaigns
development into is widespread unnecessary and inap- and the pre-eradication programme.
propriate prescription, dispensing The need for evaluation was recog-
and use of medicines. A carefully nized, but progress was slow.
public policies planned combination of regulatory In the 1970s WHO took up the
and educational measures accompa- concept of country health program-
nied by continuous monitoring can be ming as a significant innovation. It
as the top priority. effective in improving drug use, but was understood as a systematic proc-
too little is known about the final ef- ess of assessing a countrys health
fect on the health of patients. In west- problems in their socioeconomic con-
ern Europe access to drugs is ensured text, identifying areas susceptible to
through extensive publicly-financed change and formulating priority pro-
health care delivery schemes, but in grammes to induce such change. A
central and eastern Europe there has new approach of primary health care
been a marked shift towards private for the promotion of national health
financing of drugs. The accompany- services was adopted in 1975, taking
ing irrational use of drugs has created into account the socioeconomic as-
problems as regards access and pects of health and the related
affordability for larger parts of the intersectoral action. In 1994, WHOs
population. Ninth general programme of work
placed integrating health and human
development into public policies as
the top priority.
160
Achieving health for all
Current trends in health system health-for-all policy in the latter pe-
reform include increased openness to riod. From the 1970s to the present,
market forces and recognition of the the health personnel teacher training
role of the private sector, at times cou- initiative achieved a worldwide im-
pled with reduction or what is some- pact, with the recognition of health
times referred to as rightsizing of personnel education as a career
public institutions; decentralization; specialty. Health personnel education
and an emphasis on health care fi- research has led to many innovations
nancing methods, including insur- and improved understanding of adult
ance and user fees, with widespread learning and clinical decision-making
concern about resource mobilization behaviour. Starting in the 1980s, the
and cost containment. WHO has pio- relevance of health personnel to na-
neered work on monitoring health tional needs has been assessed, to
equity to inform national policies in bring about a reorientation of plan-
the health and other sectors, for ex- ning, training and utilization. The
ample supporting work in Lithuania, WHO fellowships programme has al- Technological
Sri Lanka and Zimbabwe, that ex- ways been considered relevant to
plores ways of using existing routine these processes.
data to produce policy-oriented re- The present concerns over cost progress can improve
ports on national trends in equity in and value for money have resulted in
health and health care. Other coun- important changes in the way health
tries now are asking for practical, low- care is being provided. A greater em-
prevention, diagnosis
technology methods to carry out simi- phasis on outpatient and home-based
lar work. A review of international services has led to the growth of new and treatment,
experience with health insurance categories of providers in developed
schemes covering people in the non- countries, often with very narrow
formal sector of the economy has scopes of practice. In the early 1990s but cannot substitute
been completed, as part of research a project was initiated to provide
into ways of moving from limited to Member States with a set of tools to
universal risk-sharing in low- and facilitate the planning of human re- for human resources.
middle-income countries. sources for health as well as the moni-
Technological progress can im- toring of performance. Some of the
prove prevention, diagnosis and treat- materials which have been developed
ment, but cannot substitute for hu- include the WHO toolkit for plan-
man resources. The quantity, distri- ning, training and management; mod-
bution and performance of health els for projecting workforce supply
workers is central to the efficiency of and requirements; and a manual on
the health system since they account workload indicators of staffing needs.
for as much as 70% of the recurrent The cost and availability of re-
health budget. sources will continue to be a preoc-
From 1948 to the late 1960s, cupation in the health sector. The
WHOs objective was to increase emphasis on care throughout the life
numbers of conventional health per- span will require close coordination
sonnel, with special emphasis on doc- and continuity in the provision of pre-
tors and nurses and the rapid expan- ventive and promotive, curative and
sion of medical and nursing schools. rehabilitative services. Health serv-
Training in public health was also ex- ices of the future will be provided by
panded. In the 1960s and 1970s, the multidisciplinary teams and the exist-
emphasis was on auxiliary personnel ing mandates of the established
to ensure services in isolated rural and health professions cannot continue to
difficult-access areas, spurred by the be maintained. The public and
161
The World Health Report 1998
private sectors need to develop effec-
Box 28. Global medicine needed in the 21st century tive partnerships, and the existing dis-
crepancies between them in incen-
Medical schools rightly focus teaching on the national disease and public tives and rewards need to be nar-
health panorama. However, many fail to teach even a minimum about the rowed. Regardless of which sector is
global health situation. Students of natural science, humanity, economics providing services, clinical decisions
and agronomy in most countries are generally taught more about global should take into account social and
aspects of their disciplines. Consequently, the medical profession has a weaker economic implications and moral and
voice than other professions in the discourse about global development. The ethical aspects. The client communi-
situation is improving in some medical schools, partly because of the inclu- ties of the future will be much better
sion of international health as a discipline. informed and more discriminating,
A five-week full-time course in global medicine has been given twice a and will demand a direct role in deci-
year since 1996 at the Karolinska Institute, the medical university in Stock- sions over their health. In order to
holm, Sweden. It has become the most popular of the elective courses in the cope with these changes, all health
curriculum and is presently taken by half of the students. The aim is to teach professionals will need new core
how socioeconomic, cultural and environmental factors determine the health skills, none of which are at present
of nations and how the global burden of disease and demographic patterns adequately addressed such as health
vary between and within countries. Later training in clinical medicine is put in economics and management, ethics
both a historical and a global perspective by a review of the disease transi- and computer skills in addition to
tion, from infectious diseases and malnutrition affecting mainly children to the skills required in their own spe-
various patterns of chronic diseases in adults. Students learn to use differ- cial fields.
ent sources of health and demographic indicators in problem-based learning In recognition of the need for the
sessions where they analyse the health profiles of different countries. The medical profession to participate in
division of countries into developing and industrialized is replaced by a new global development, some medical
taxonomy with several groups reflecting the continuum of health status that schools have decided to teach interna-
is determined by both economic development and degree of equity. Global tional health as a discipline (Box 28).
variations in health policy and health service systems, modern as well as As health technologies become
traditional, and the work of international health organizations are reviewed. more complex and costly, and as the
Teaching about food security and food culture ends the first part of the course. application of new and existing tech-
The last two weeks of teaching are given by either of the Medical Col- nologies becomes more refined, mak-
leges in Blantyre, Malawi, and Trivandrum, India. Students pay for their own ing the right decisions about the allo-
travel and the Karolinska Institute pays the tuition fees from its core budget. cation of often scarce resources has
Students learn about cost-effectiveness as they admire the clinical skills of become more difficult.
the teachers in India and in Africa with access to few of the diagnostic tech- Reproducibility and comparabil-
niques used in Sweden. It comes as a surprise to students to learn how ity of results are essential to the suc-
much health can be improved with few resources if the primary health care cess of health laboratories. In 1972,
strategy is optimally applied. Home visits to families under guidance from the World Health Assembly adopted
community nurses provide unique understanding of the tremendous global a resolution on standardization of di-
inequity in health-determining life conditions. Collaborative projects and re- agnostic materials. In 1976, WHO
ciprocal exchanges of students and teachers result from the contact cre- established the first international ex-
ated. Students evaluations are very positive and their comments (e.g. I lost ternal quality assessment scheme
prejudices and gained a new view of the world) indicate that the impact goes (IEQAS) in clinical chemistry to as-
far beyond learning new facts. The course provides knowledge and perspec- sist countries in developing their own
tives that will be useful in the next century whether the student goes on to national schemes for laboratory stand-
work in pharmaceutical research, clinical practice or becomes an actor in ardization and quality assurance. Cur-
the discourse on global development. rently, 262 key laboratories in 113
countries are participating in the
Personal communication from Dr H. Rosling, Professor in International Health, WHO IEQASs. Unfortunately, the
Karolinska Institute, Stockholm, Sweden.
high cost of modern laboratory tech-
nology is an impediment to its trans-
fer to countries in need.
162
Achieving health for all
WHO has always emphasized the quality testing of imported pharma-
provision and improvement of the ceutical products for locally manufac-
quality of radiological services for di- tured drugs and for teaching material.
agnosis and therapy in public health Since 1982 WHO has docu-
care, areas that have seen spectacu- mented the increase in counterfeit
lar progress. In industrialized coun- and poor-quality drugs in interna-
tries a number of technologically ad- tional commerce. Most counterfeit
vanced imaging modalities (e.g. com- drugs contain fewer active ingredients
puterized tomography and magnetic than claimed, wrong ingredients, or
resonance imaging) have become no ingredient at all, which makes
available not only in university hospi- them less effective or even toxic.
tals and specialized health centres but WHO organized an international
also in regional and district hospitals. workshop on the subject in 1997,
In developing countries the most which recommended the establish-
positive trend is the rapid increase of ment of adequate and vigorous na-
diagnostic ultrasound units, including tional regulatory systems and of an About two-thirds
their availability in rural areas. international network of drug regu-
About two-thirds of the popula- latory offices, as well as closer collabo-
tion in developing countries have no ration with customs, police, profes- of the population in
access to essential radiological serv- sional organizations and the pharma-
ices. To respond in the most optimal ceutical industry.
way to the needs of such countries, The Organization first recog-
developing countries
WHO developed the basic radiologi- nized the potential benefit of tradi-
cal system during the period 1975- tional medicine and launched an have no access to
1985 and in 1995, technical specifi- initiative to assess health services
cations were published for its updated provided by traditional practitioners
version, the WHO imaging system for in 1978. To this day, a large propor- essential radiological
radiography. Technical specifications tion of the population in many de-
for general-purpose and special- veloping countries still relies mainly
purpose ultrasound scanners were on traditional practitioners and me- services.
published, as well as four manuals to dicinal plants to satisfy primary
provide logistic support in using these health care needs. Since 1991, WHO
technologies. has promoted the integration of tra-
The international pharmacopoeia, ditional medicine into national
which was established by the First health care systems and the proper
World Health Assembly in 1948, sets use of traditional medicine through
out recommended procedures of the development of technical guide-
analysis and specifications for phar- lines and international standards,
maceutical substances. It offers an particularly in the field of herbal
alternative to the often very sophisti- medicines and acupuncture. The
cated and expensive methods de- major objective now is to reach in-
scribed in other pharmacopoeias. It ternational agreement on policies,
is most typically used as a reference regulations, registration and techni-
tool for the development of national cal standards in traditional medicine,
standards, as well as for day-to-day particularly at the regional level.
163
WHO worldwide
Chapter 6
WHO worldwide
C
hapter XI of WHOs Consti- The decentralization of the activi-
tution provides that the ties of WHO was one of the most dif-
World Health Assembly may ficult and complex problems facing the
establish a regional organization to meet First World Health Assembly. How
the special needs of a geographical area. many regions should be created? What
Each regional organization is an inte- groups of countries should they in-
gral part of WHO, and consists of a re- clude? How soon should regional or-
gional committee and a regional office. ganizations be instituted? What would
Regional committees are composed of be the financial impact? It was sug-
representatives of the Member States gested that the following factors should
and Associate Members in the region be taken into account: the health level
concerned, and their functions include of countries to be included; the possi-
the formulation of policies governing ble existence in those countries of a
matters of an exclusively regional char- permanent epidemic focus; the extent
acter, and the supervision of regional to which they had managed to over-
office activities. The regional office is come the health consequences of war;
the administrative organ of the regional the efficiency of their health adminis-
committee, and also carries out within tration; and their capacity to resolve
the region the decisions of the World their problems.
Health Assembly and Executive Board. Six WHO regions were estab-
The head of the regional office is the lished: Africa, the Americas, Eastern
Regional Director appointed by the Ex- Mediterranean, Europe, South-East
ecutive Board in agreement with the Asia, Western Pacific. The Assembly
regional committee. decision as regards Europe was lim-
ited to the setting-up at an early date
of a temporary special administrative
Map 11. WHO regional offices and the areas they serve, 1998 office to deal with the health reha-
bilitation of war-devastated countries.
In the Eastern Mediterranean area,
COPENHAGEN it was decided to integrate the exist-
HQ ing Alexandria Regional Bureau with
WASHINGTON NEW
DELHI WHO as soon as possible. An agree-
ALEXANDRIA ment was concluded with the Pan
MANILA American Sanitary Organization: the
Pan American Sanitary Bureau in
BRAZZAVILLE
Washington, DC, would assume, in
addition to its former functions, the
new role of WHO Regional Office for
the Americas.
Map 11 shows the distribution of
Regional Office countries among the six WHO regions
WHO 96460
African Region South-East Asia Region Eastern Mediterranean Region and the location of the regional
Region of the Americas European Region Western Pacific Region offices.
165
The World Health Report 1998
46 Member States
Population (1997): 612 million
GNP per capita
Regional average (1995) $ 564
min.: Mozambique $ 80
max.: Seychelles $ 6 620
Annual average growth rate
(1985-1995)
min.: Gabon -8.2 %
max.: Botswana 6.1 %
166
WHO worldwide
sponses in four strategic areas: devel- tries, the targets in terms of ratio to
opment of human resources for the population have not been
health; promotion of environmental achieved. Qualified specialists were
hygiene; epidemiological surveillance produced but did not always remain
and control of communicable dis- in the countries or the public sector
eases; and strengthening of health because of the brain-drain phenom-
services. enon, or because they were lured
Many countries made the devel- away by non-national institutions. In
opment of infrastructure the focus of some cases, the training provided was
their health policy, to help improve not entirely adequate or appropriate.
the coverage and management of the The reform of medical education
health problems of their populations. has received special attention. Efforts
But the results obtained were uneven are being made to define the profile
because of limited investment capac- and the skills of the 21st century medi-
ity. Quite often, achievements could cal practitioner, to improve the func-
not be maintained except through tions of nurses and midwives and to
international cooperation and com- redirect them towards primary health
munity initiatives. Infrastructure ex- care services. Unfortunately, the im-
pansion was noted in some cases but pact of these reforms has not yet been
did not measure up to needs. felt. The low output of health institu-
The deterioration of the economic tions and poor performance of health
and financial situation in recent years personnel are still major concerns in
has been felt particularly in the health a large number of countries. The
sector. Health investment has virtu- impoverishment of health personnel
ally ceased. The social sectors, includ- is undermining the public sectors
ing the health sector, have been the capacity to respond.
hardest hit by the worsening trend of An increasing number of countries
budget deficits. There is still imbal- are worried about the general degra-
ance between expenditure on terti- dation of the environment and the
ary care and expenditure for local inability of their health structures to
care, to the detriment of the latter. address the problem. The substantial
The development of human re- increase in the volume of industrial
sources for health has been a top and domestic wastes poses a threat,
priority and substantial efforts have given the inadequacies of waste dis-
been made to provide a generation posal systems in a large number of
of trained personnel of all categories, countries. The risk of water contami-
such as physicians, nurses, midwives, nation and soil degradation by chemi-
laboratory technicians, sanitary engi- cal pollutants is also a real problem,
neers, etc. However, in most coun- yet to be solved in many cases.
167
The World Health Report 1998
Death rates: age- and sex-standardized, and age-specific, Even so, plans were developed
1955-2025 estimates (per 100 000 population) without a clear vision and, in some
cases, there is no long-term planning
Age group 1955 1975 1995 2025 culture. Sometimes, lack of political
commitment and instability in coun-
Age- and sex-standardized 2 670 2 013 1 645 936
tries have limited the capacity to re-
0-4 7 243 4 966 3 439 1 431
spond to needs. Management capac-
5-19 1 178 821 612 238 ity, including capacity to implement
20-64 1 446 1 099 994 544 plans, remains weak. Health informa-
65+ 9 299 8 011 7 159 5 717 tion systems are still inadequate. Ac-
cess to health care is generally ineq-
uitable, particularly for the rural
A decline in food self-sufficiency, populations who are underserved.
as well as the risk of chronic famine, Health for all, but not health for eve-
have been observed in many coun- ryone, has been given due considera-
tries of the Region in recent years. tion, but insufficient emphasis has
Furthermore, food insecurity and been given to ensuring access to a
improper dietary habits bring a phe- minimum package of health care,
nomenon of deficiency malnutrition including curative care.
which particularly affects preschool Public interest in health matters
children and pregnant women. has grown in recent years, partly as a
The number of smokers continues result of the increase in the volume
to increase in the Region, particularly and circulation of information pro-
among adolescents. Similarly, abuse vided by the media. More and more
of alcohol and other toxic substances, newspapers and magazines are devot-
including drugs, calls for vigorous ing special columns and pages to
action. health. This has improved knowledge
Access to safe water and ad- and stimulated the quest for informa-
equate sanitation is still far from the tion.
set targets, including those of the In- Economic difficulties and the de-
ternational Drinking Water Supply clining literacy rate in some countries,
and Sanitation Decade. This is par- or among certain population groups,
ticularly true in the rural parts of most are hampering efforts made in public
countries, where the average propor- education. Some countries have
tion of people with access to safe therefore explored innovative means
drinking-water is below 60%, while of ensuring the adequate production
access to appropriate sanitation is less and distribution of information on
than 50% (as compared to the 90% health. There is increasing recogni-
targeted for the year 2000). tion of the need for a national policy
National health systems have been on health information and education,
developed and consolidated, with especially within the context of social
special emphasis on the district health mobilization for health.
subsystems. Better integration and The countries in the Region have
management of priority programmes made substantial investment in ma-
such as immunization, control of ternal and child health, and inte-
diarrhoeal diseases, essential drugs gration of activities has been im-
and vaccines constitute important proved, especially immunization serv-
achievements, since commendable ices and maternal and child health
results have been observed in terms services. Even so, less than 50% of the
of service coverage and impact on countries have a coverage rate of over
diseases. 50% for antenatal care, and less than
168
WHO worldwide
169
The World Health Report 1998
35 Member States
1 Associate Member
Population (1997): 792 million
GNP per capita
Regional average (1995) $ 12 293
min.: Haiti $ 250
max.: United States $ 26 980
Annual average growth rate
(1985-1995)
min.: Nicaragua -5.4 %
max.: Chile 6.1 %
170
WHO worldwide
between 1990 and 1996) reflects im- tween one-quarter and one-half of
provement when compared to the 1960-1964 levels) occurred in the
1980s, it still has not recovered to lev- higher-income countries. For the
els achieved in decades before that. lower-income countries, the reduc-
Demographic trends in the Re- tion has remained at levels between
gion have not changed. The decline 25% and 38% of 1960-1964 levels.
in fertility and the ageing and urbani- The population aged over 65 years of
zation of the population have per- the countries with the lowest per
sisted and even intensified, as have capita income has seen the most sig-
the inequities and inequalities evi- nificant increases in mortality.
denced in the socioeconomic and Between 1960 and 1970, the over-
demographic situation of the coun- all birth rate was, on average, over
tries. By the mid-1990s, the popula- 40 per 1000 population; whereas for
tion of the Americas reached 774 mil- 1998, it is estimated to be 19.2 per
lion (from 331 million in 1950), nearly 1000. Fertility rates have also de-
13% of the current world population, creased significantly in all countries.
with estimates indicating that it will In general, it is predicted that both
reach over 1 billion by the year 2025. birth rates and fertility rates will con-
In terms of population, the relative tinue to decline, keeping total popu-
weight of Latin America has in- lation growth at a slow pace, despite
creased over time: in 1950 it ac- the reductions in mortality. The popu-
counted for 48.7% of the population lation over 65 is expected to continue
of the Hemisphere; in 1995, 61.3%; to grow at an average of 3% per year,
and, according to current projections, accounting for the growing impor-
by 2025 it will have 65.1% of the Re- tance of this population group.
gions population. The population of The working population consti-
North America, in contrast, has fallen tutes on average 40 - 60% of the gen-
from 50.1% in 1950 to 37.7% in 1995, eral population of the Region. The
with estimates putting it at 33.9% by economically active population was
2025. estimated at 357.5 million for 1995
Total mortality, with rare excep- and is projected to grow to 399 mil-
tions, continues to present a decreas- lion by the year 2000. The changes in
ing trend, with continued increases in the structure and composition of the
life expectancy at birth. These trends work force also have an impact on
are expected to continue into the next health. The reduction in the real in-
millennium. The percentage of come of families, as well as changes
deaths in children under 1 year of age in family structure, place on women
has decreased in all countries. How- and children the major part of the
ever, the most marked reductions (be- burden of developing subsistence
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Death rates: age- and sex-standardized, and age-specific, causes of death in the population un-
1955-2025 estimates (per 100 000 population) der 5 in most of the medium- and low-
income countries of the Region.
Age group 1955 1975 1995 2025 Chronic undernutrition has replaced
acute malnutrition in infancy, which,
Age- and sex-standardized 1 173 873 636 462 together with micronutrient deficien-
0-4 2 709 1 690 722 374 cies, makes up the nutritional defi-
5-19 287 160 86 52 ciency of the lower-income countries.
20-64 730 544 409 340 The AIDS and HIV epidemic
65+ 6 105 5 650 5 289 4 348 continues, while malaria has ex-
panded its borders and the popula-
tion at high risk has increased, and
strategies in order to face poverty. rent trends persist, the problem is dengue continues to be a serious
These can be most readily seen in the likely to increase, reaching epidemic threat. In the case of malaria, mor-
massive incorporation of women into proportions in some countries. In bidity (as measured by the annual
precarious working conditions and in Latin America and the Caribbean, the parasite infection rate) began a steady
the early insertion of adolescents and average mortality and disability attrib- increase in the mid-1970s. There was
minors into the workforce. utable to occupational accidents, is a decrease in 1993 which reversed in
calculated to be four times greater 1994 and 1995, reaching rates that are
Health trends than that notified by developed coun- more than twice those registered two
tries, at an estimated 300 daily deaths decades ago. A similar trend can be
Mortality indicators have shown im- of workers. observed with the resurgence of den-
provement in all the countries of the Because one of the major func- gue. Cholera has become endemic in
Americas over the last 35 years and, tions of the Organization is to moni- several areas and countries of the
with rare exceptions, in all age groups. tor the human condition in order to Region, although case-fatality rates
However, the favourable evolution in detect where inequities exist and have continued to be low.
mortality and in the health conditions whether the interventions designed to In order to provide a broader re-
of the population hides enormous dis- correct them are effective, methodo- sponse to the threat posed by new
parities between and within coun- logical advances that allow the analy- and emerging diseases, the Organi-
tries. For children under 1 year, the sis of differences among and within zation will be dealing with foodborne
gaps in mortality were stable or de- countries have been developed. The illness and outbreaks through the
creasing for the countries in the mod- distribution and spatial dynamics of newly redefined Pan American Insti-
erate income group, but they were inequalities in health status and liv- tute for Food Protection and Zoon-
high and tended to increase in coun- ing conditions are being analysed by oses in Argentina and with new and
tries belonging to the lower income coupling cartographic information emerging zoonoses such as hanta-
groups. with basic data on health indicators. virus, plague and equine encephali-
However, when age-adjusted mor- Much has been accomplished in tis through the Pan American Foot-
tality rates are compared between the struggle against disease in the and-Mouth Disease Center.
countries of similar income, reducible Americas. The Region remains free Despite the progress in expand-
gaps in avoidable deaths are signifi- of circulating wild poliovirus, and ing coverage, there are serious prob-
cant. The variation of mortality in the there has been enormous progress lems related to water quality and
Region is notable. However, it is pos- towards the elimination of measles water supply, as well as to solid waste
sible to state that in the country with and neonatal tetanus. The number of disposal. As a result of the cholera
the highest per capita income, 4.7% episodes of acute diarrhoeal disease epidemic, countries have increased
of mortality in the age group 45-64 have been markedly reduced, and investment in water supply and sani-
could have been avoided, whereas in there have been significant reductions tation. The 1995 coverage for the to-
the country with the lowest income, in mortality due to intestinal and tal population with access to water
preventable causes accounted for 62% acute respiratory infections. Despite supply through house connections
of mortality in the under-65 age group. these advances, diarrhoeal diseases, and other acceptable means was 73%.
Violence in the Region is respon- acute respiratory infections, and mal- In the field of sanitation, by 1995 the
sible for 7-25% of mortality. If cur- nutrition continue to be the leading total coverage of wastewater and ex-
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Leading clusters of diseases/conditions, Region of the Americas, The need for financing and other
selected years (indicative list) resources has been considered a con-
straint to expanding and maintaining
Disease category 1960 1980 1997 2025 health programmes. In many coun-
tries decentralization to the local level
Infectious and parasitic 1 1 2 4 and greater community involvement
Perinatal and maternal 2 3 5 5 could contribute to the sustainability
Malignant neoplasms 5 5 4 3 of activities.
Endocrine and nutritional
Emphasis will also be given to the
Mental and behavioural
crucial importance of actions directed
Circulatory system 4 4 3 1
towards safeguarding the planet, par-
Respiratory system
All external causes 3 2 1 2 ticularly in light of events that are af-
fecting natural resources and produc-
ing ecological changes. The emer-
gence of new diseases which threaten
creta disposal facilities had increased spent over $1 billion on health, or human existence is linked to these
to 69%. Urban services remained about $240 per capita. changes. Natural disasters and their
constant at 80%; however, rural serv- effects on drinking-water safety and
ices were extended to approximately Future prospects the availability of food and shelter
40% of the population. One of the could have been given more atten-
most critical sanitary problems in In contrast to the 1970s, infrastruc- tion, particularly in light of the Re-
Latin America remains the lack of ture development policy in the past gions vulnerability to hurricanes, vol-
sewage treatment. A 1995 survey in- 15 years has stagnated and is currently canic activity, earthquakes, and other
dicated that the percentage of sew- one of the components with the great- natural disasters.
age collected that receives treatment est need for state policy support. In- The vision of health for all repre-
is just above 10%. frastructure development is one com- sents a desired future state that is
In response to increasing aware- ponent that requires strengthening being approached by renewing com-
ness among Member States that within the health sector reform proc- mitment to the goal and by imple-
noncommunicable diseases account esses. Another is improving mecha- menting suitable strategies and con-
for nearly two-thirds of deaths in the nisms to ensure the supply and avail- crete actions. This vision may be sum-
Americas, that these diseases mainly ability of essential drugs and other marized as a shared understanding of
result from risk factors that can be supplies. health in which the energies of the
modified, and that increasing the em- There have been significant Hemisphere respond to the chal-
phasis on prevention could improve changes in the formulation and im- lenges that arise for the achievement
health status, the CARMEN pro- plementation of national and health of sustainable human development
gramme was developed. It takes an sector policy. Decentralization, social with dignity and equity.
integrated approach that combines participation, and inter- and intra- With the new millennium ap-
clinical prevention for individuals with sectoral coordination are part of the proaching, Member States should
health promotion directed at the gen- strategies that have been promoted renew their commitment to the
eral population. CARMEN projects and that in some places have yielded goal of health for all and its health
reach their audience through commu- positive results. strategies within the context of the
nity, workplace and school settings, as The countries have accorded high social, economic, political, envi-
well as through local health services. priority to the care of children under ronmental, and technological
The financial constraints in the 5 and women. Action has been geared trends that are affecting the health
social sectors over the past decade towards improving coverage. How- of the populations, the environ-
have increasingly revealed the serious ever, the populations need for access ment, and the health services, giv-
limitations of institutions in terms of persists owing to a variety of con- ing priority to the adoption of poli-
resource management, a situation straints. The Organization is respond- cies to resolve their health prob-
that has worsened due to rising costs ing by promoting the trend towards lems in a sustainable manner and
in the services. In 1994 the countries the delivery of integrated health serv- steadily improve the quality of life
of Latin America and the Caribbean ices to priority population groups. of their peoples.
173
The World Health Report 1998
22 Member States
Population (1997): 473 million
GNP per capita
Regional average (1995) $ 1 385
min.: Yemen $ 260
max.: United Arab
Emirates $ 17 400
Annual average growth rate
(1985-1995)
min.: Jordan -4.5 %
max.: Tunisia 1.9 %
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WHO worldwide
WHO response to change from health for some to health for all.
During this period, many nationals
WHO has adjusted its activities to who became responsible for various
respond to changing patterns of ill- aspects of public health were trained
ness. Before 1970, emphasis was through WHO fellowships. WHO
placed on the control of infectious organized some regional and inter-
and deficiency diseases. Malaria and regional training courses, such as the
other parasitic diseases, tuberculosis interregional training course on epi-
and other bacterial diseases received demiological surveillance.
priority attention through what be- Many countries of the Region
came known as vertical programmes. were in the vanguard of primary
In these programmes (at that time health care, and the spirit of collabo-
called projects), WHOs contribution ration between Member States was
included the provision of a suitable evident. One example was the deci-
expert or a team of experts to provide sion of seven countries (Iran, Iraq,
technical guidance and train national Kuwait, Libya, Qatar, Saudi Arabia
counterparts. Support included the and United Arab Emirates) to curtail
provision of supplies and equipment their own demands on the Organiza-
to ensure the success of the project. tions budget in favour of expanding
Some of these projects were very suc- activities in the less-favoured coun-
cessful (e.g. the eradication of small- tries, in addition to their normal con-
pox and the control of bejel). Success tribution to the WHO budget. There
was less evident in malaria control/ are many other examples of bilateral
eradication in some countries. support directly and through WHO
In the 1970s and early 1980s, the between the well-to-do countries and
vertical programme approach contin- the less fortunate ones.
ued. These projects meant health for The third period started in the
some, but in some cases as soon as early 1980s when available regular
WHO support came to an end, activi- budget resources saw no real in-
ties were not maintained by national crease, coinciding with increasing
authorities, so the problem returned. emphasis on chronic noncommunic-
It became clear that the need was able disease. This meant globally and
rather for collaboration in the devel- regionally significant decreases in the
opment of national health care sys- allocation for communicable disease
tems and health manpower develop- and unfortunately a resurgence of
ment, since many newly independent these diseases which was realized
states in the Region wished to build rather late in some cases. Many of the
up their public health infrastructure achievements of WHOs global pro-
and respond to the new move away grammes reflect those of the Region.
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The World Health Report 1998
Death rates: age- and sex-standardized, and age-specific, proaches in all national programmes.
As a result, whenever national pro-
1955-2025 estimates (per 100 000 population)
grammes are being structured, it is
now the practice to formulate objec-
Age group 1955 1975 1995 2025
tives, to set measurable targets, to
Age- and sex-standardized 2 453 1 698 1 057 630 identify approaches to reach these
0-4 7 395 4 523 2 241 874 targets, to clearly spell out activities
5-19 898 504 237 91 and to develop indicators for meas-
20-64 1 260 833 486 303 uring achievements.
65+ 9 002 7 937 6 305 5 008 In most countries of the Region,
the spiritual dimension plays a con-
siderable role in daily life. It is insepa-
Programmes which were specifically WHOs role in this process was rable from peoples behaviour and
developed or initiated in the Region mainly of a catalytic nature, such as beliefs. WHO has initiated activities
are described below. facilitating political commitment, that help Member States to gain the
During the first regional commit- raising awareness, encouraging train- active support of religious leaders in
tee held in 1949, the Regional Direc- ing and capacity building in commu- transmitting health messages to the
tor indicated that health is not some- nities, and supporting income-gener- community. Information and training
thing which can be done to the peo- ating schemes, mostly on a loan materials for religious leaders and for
ple, it must be done for themselves basis. dissemination to the public have been
by themselves. This forward-looking In just over 10 years, the basic planned for many priority health pro-
view anticipated the importance of development needs approach has grammes such as control of smoking
community participation, and be- gained momentum in the Region. and drug abuse, prevention of water
came 30 years later one of the pillars New areas have been established in pollution and control of communica-
of the health-for-all policy through more and more countries. Its success ble diseases. Publications such as the
primary health care. Since in the ab- has attracted great interest and inputs six booklets in a series on health edu-
sence of a satisfactory quality of life, from many partners, mainly national cation through religion have helped
primary health care alone cannot authorities and regional and global to show that the changes in behaviour
maintain and promote health in its full development agencies. WHO sup- required to improve health conform
sense, WHO has introduced the ba- ports the building-up of national ca- with religious teaching. The spiritual
sic minimum needs (subsequently pabilities to manage this programme, dimension in promoting healthy life-
called basic development needs) ap- as well as research to document suc- styles was the subject of a conference
proach as a programme of collabora- cesses and to find ways of replication held in 1989 in Amman which ended
tion with Member States of the Re- and sustainability. in the Amman Declaration on Health
gion. In introducing this programme The Member States in the Region Promotion.
in 1987, the Regional Director stated no longer regard WHO as an extra- From the outset it was realized
that it would be a mockery to exhort neous agency providing technical and that preparing school teachers by pro-
people to lead healthy lives when they financial assistance, but as a full part- viding them with basic facts on the
do not have sufficient or safe water ner, thanks to innovative thinking promotion and protection of health
to drink, enough food, or access to such as the joint programme review of schoolchildren is important, and
education for their children. missions which were initiated in that the participation of educational
This new concept aimed at achiev- 1983. These missions are carried out authorities in this regard is basic.
ing a better quality of life. It is a par- every biennium and are intended to Until 1966, health eduction was
ticipatory process of integrated socio- review national achievements for mostly mass-oriented and not focused
economic development based on self- health for all and to identify and plan on the specific needs of various popu-
reliance, and self-management by programmes of collaboration for the lation groups. In 1965, the Regional
organized communities supported by coming biennium. This exercise is no Committee passed a resolution re-
coordinated intersectoral action. It is longer restricted to reviewing pro- questing national authorities to give
a clear way of involving people in run- grammes with WHO financial input; high priority to preparing teachers for
ning their own affairs, thus ensuring it now also involves a process of think- involvement in health education.
accountability and transparency. ing and introducing structured ap- Scattered efforts were then made for
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177
The World Health Report 1998
51 Member States
Population (1997): 869 million
GNP per capita
Regional average (1995) $ 11 126
min.: Tajikistan $ 340
max.: Luxembourg $ 41 210
Annual average growth rate
(1985-1995)
min.: Georgia -17.0 %
max.: Ireland 5.2 %
178
WHO worldwide
179
The World Health Report 1998
Death rates: age- and sex-standardized, and age-specific, eastern Europe, extensive pollution
1955-2025 estimates (per 100 000 population) continued during the 1980s but im-
proved somewhat in the 1990s, largely
Age group 1955 1975 1995 2025 owing to the economic collapse and
closure of big industries that followed
Age- and sex-standardized 949 749 660 473
the major political and economic up-
0-4 1 426 811 561 288
heavals in 19891990. In the south-
5-19 150 88 73 32
eastern part of the Region, over 100
20-64 655 536 499 375
million people did not have access to
65+ 6 523 5 908 5 819 5 112
sufficient quantities of safe drinking-
water in the early 1990s. While many
of these problems (establishment of
Region suffered stagnating economic since 1994. Standardized death rates safe drinking-water facilities, indus-
growth, rising unemployment, in- for infectious and parasitic diseases trial pollution control and waste man-
creasing disparities in income distri- have been declining between 1975 agement) could readily be tackled if
bution, more extensive migration, a and 1991, when they started increas- the necessary economic resources
loss of social cohesion and increased ing. For circulatory diseases, they were available, others, such as deal-
violence, all of which have an impact were stagnant between 1975-1985, ing with the aftermath of the
on health. Most countries were un- but overall the mortality pattern for Chernobyl disaster, represent formi-
der pressure to reduce costs in the major disease categories has changed dable, complex challenges with no
health sector, and people became in- little during the period 1980 and easy solutions in sight.
creasingly dissatisfied with the serv- 1995. Transfrontier environmental
ices provided. There was a trend to- pollution and hazardous wastes were Current situation
wards the globalization of economic more effectively controlled, and the
activity, on the one hand, and one to- quality of drinking-water improved. There are now 51 Member States in
wards decentralization, privatization, However, inequalities in health sta- the Region (as opposed to 18 in 1951).
and an increase in the number of tus between countries had not gen- The overall population growth rate is
nongovernmental organizations in- erally declined and in some cases had very low (under 1%) and in many
volved in health, on the other. How increased, particularly between the countries it is close to zero or nega-
far this is leading to a weakening of central and eastern parts of the Re- tive. Throughout the 1990s, birth
national governments ability to influ- gion and the rest. Also, tobacco use rates have been decreasing in many
ence health developments is not clear. and alcohol and drug abuse contin- countries of eastern and central
In 1990 the Regional Office cre- ued to be serious lifestyle problems. Europe to levels previously observed
ated a new programme EURO- Progress in achieving cooperation only in wartime. Consequently, popu-
HEALTH to support the develop- between different sectors of govern- lation ageing has accelerated. The
ment of health for all in the countries ment and with other sectors, such as health situation has worsened consid-
of central and eastern Europe, includ- private industry, in the interest of erably in the transition economies of
ing the central Asian republics. Help- health were disappointingly low. central and eastern Europe, where
ing these countries to close the health By the mid-1990s, the basic prin- expectations in the early 1990s
gap that lies between them and other ciples of the health-for-all policy had quickly proved to be over-optimistic.
Member States of Europe, and to become widely accepted in virtually Although in some countries of
plan for a healthy future, is perhaps every country of the Region, and al- western, northern and southern
the most important health-for-all most all had incorporated at least Europe there has been slight progress
challenge that will continue into the some parts of them in their national towards increasing life expectancy, on
21st century. policies. In countries that took this the whole the trend is now negative.
Life expectancy at birth for the challenge most seriously, major im- Average life expectancy in the Region
Region as a whole increased during provements were seen in the way re- decreased from 73.1 years in 1991 to
the period 1975-1991 except for a sources for health were mobilized. 72.4 in 1994, due almost exclusively
decline in 1983. From 1992 to 1994 There were noticeable improve- to a sharp deterioration in the situa-
it declined again, but this negative ments in pollution levels in the west- tion in eastern Europe. If the trend
trend seems to have been reversed ern part of the Region. In central and from 1980 to 1994 continues, the
180
WHO worldwide
181
The World Health Report 1998
10 Member States
Population (1997): 1 457 million
GNP per capita
Regional average (1995) $ 532
min.: Nepal $ 200
max.: Thailand $ 2 740
Annual average growth rate
(1985-1995)
min.: Bangladesh 2.1 %
max.: Thailand 8.4 %
182
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183
The World Health Report 1998
Death rates: age- and sex-standardized, and age-specific, iour groups. The epidemic in Asia is
1955-2025 estimates (per 100 000 population) still at an early stage and the situa-
tion demands urgent control meas-
Age group 1955 1975 1995 2025 ures that need to be sustained. While
the spread of AIDS in various popu-
Age- and sex-standardized 2 431 1 655 1081 643 lation groups is particularly remark-
0-4 7 298 4 290 1 992 797 able in countries such as India,
5-19 849 473 254 73 Myanmar and Thailand, the potential
20-64 1 234 865 569 383 for spread within other South-East
65+ 8 939 7 657 6 771 5 363 Asian countries is enormous. It is es-
timated that by the end of the cen-
tury, 8-10 million men, women and
mortality. There are over 1 million nesia and Myanmar, and is deterio- children are likely to become infected
under-5 deaths each year from diar- rating in Bangladesh. The resistance with HIV within the Region, account-
rhoea. of P. falciparum to various drugs con- ing for over 25% of the global cumu-
Tuberculosis still kills more adults stitutes one of the main technical lative infections.
than any other single infectious dis- impediments to malaria control in the It is estimated that there were 150
ease. It is estimated that 3.5 million Region. Drug resistance has been in- million cases of curable sexually trans-
new cases occurred in the Region creasing and is now pronounced in all mitted diseases among adults in the
during 1995, representing about 40% of the malaria-endemic countries. Region in 1995. Syphilis accounts for
of the global disease burden. This in- Vector resistance to insecticides and approximately 5-8 million cases, gon-
cludes 2.3 million new cases in India, changes in vector behaviour to avoid orrhoea for 29 million, chlamydial
0.5 million in Indonesia, and 0.4 mil- sprayed surfaces are considered to be infections for 40 million, and tricho-
lion in Bangladesh. About 1 million some of the factors impeding malaria moniasis for 75 million cases. Al-
people died from tuberculosis in the control efforts. Other administrative though data from countries in the
Region during 1997, accounting for and operational constraints include Region on the incidence and preva-
nearly 40% of global deaths from the inadequate budgets, shortage of lence of sexually transmitted diseases
disease. HIV-positive persons with a trained personnel at all levels, uncon- are inadequate, recent data from
prior tuberculosis infection are espe- trolled large-scale population move- Thailand show a declining trend.
cially vulnerable to developing active ments, and inadequate intersectoral In addition to the current commu-
tuberculosis. For example, 60-80% of collaboration and community partici- nicable diseases, there are viral infec-
people with AIDS in India, Myanmar, pation. WHO is assisting Member tions that have the potential to cause
Nepal and Thailand develop tubercu- States in implementing the adapted epidemics, including hantaviruses,
losis. global malaria control strategy which yellow fever and filoviruses. Hanta-
Malaria still dominates the dis- emphasizes early diagnosis and treat- virus infection in patients with
ease pattern in the Region, with 1.2 ment with effective antimalarial haemorrhagic fever and kidney in-
billion people in eight endemic coun- drugs, and selective, cost-effective volvement have been clinically and
tries living in malarious areas. The vector control measures. Emphasis is serologically documented only in
overall malaria situation has been currently being placed on coordina- Myanmar to Sri Lanka. In addition,
static over the last 12 years, with re- tion of malaria control in border ar- antibodies to hantaviruses have been
ported cases ranging from 2.5 to 3.4 eas, upgrading managerial and tech- detected in samples of human and
million, and reported deaths from nical capability and capacity within rodent sera from India, Indonesia and
5000 to 8000. During 1996 the re- national programmes, and develop- Thailand. These findings suggest that
ported number of cases and deaths ment of capabilities in applied re- there is wide circulation of
due to malaria were nearly 3.4 mil- search methodologies. hantaviruses in both human and ro-
lion and 8000 respectively. The esti- The HIV/AIDS pandemic reach- dent populations in the Region. Al-
mated incidence and number of ed the Region relatively late, but has though Ebola haemorrhagic fever has
deaths are much higher. At the coun- spread rapidly in the last few years. not occurred in the Region, antibod-
try level, the malaria situation is im- Infection rates have now begun to ies to Ebola-related filoviruses have
proving in Nepal, Sri Lanka and Thai- increase in the general population in been detected in a species of mon-
land, is static in Bhutan, India, Indo- addition to those in high-risk behav- key from Indonesia. Until now, how-
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WHO worldwide
Leading clusters of diseases/conditions, South-East Asia Region, Another disease that is increasing
selected years (indicative list) dramatically with urbanization and
changing lifestyles and nutrition hab-
Disease category 1960 1980 1997 2025 its is diabetes mellitus. Whereas its
prevalence has been found recently
Infectious and parasitic 1 1 1 3 to be about 2% in rural populations
Perinatal and maternal 3 3 3 in India, its prevalence in urban ar-
Malignant neoplasms 2 eas is about 3% with local peaks as
Endocrine and nutritional 2 2 5 high as 8%. Similar results were found
Mental and behavioural 4
in Thailand in 1991.
Circulatory system 2 1
Forecasts envisage morbidity and
Respiratory system
mortality burdens still dominated pri-
All external causes
marily by re-emerging and emerging
infectious diseases with the beginning
of a shift towards noncommunicable
ever, there has been no report of hu- Democratic Peoples Republic of chronic diseases for Bangladesh, Bhu-
man illness associated with the Ebola- Korea, Sri Lanka and Thailand, in tan, most of the states of India,
related virus. Yellow fever also has some states of India, which have Maldives, Myanmar and Nepal.
never been reported in the Region. achieved high levels of life expect- Noncommunicable diseases and ac-
The recent epidemic of yellow fever ancy, and to some extent in Indone- cidents will affect to a greater extent
in Kenya, however, makes it appar- sia, where noncommunicable diseases the more advanced countries of the
ent that the virus could spread to have more recently become a major Region which have achieved higher
coastal parts of East Africa and from public health problem and one of the levels of life expectancy. The HIV/
there to Asia. Since the mosquito vec- main causes of death. At present the AIDS epidemic will be present
tor of yellow fever is widely prevalent risk of death from noncommunicable throughout the Region, being close
in the countries of the Region, and diseases during adulthood is consid- to its peak in India, Myanmar and
since the population has little or no erably higher in the developing world, Thailand, and rapidly spreading in
immunity to the disease, there is con- including South-East Asia, than in some other countries.
siderable potential for yellow fever to established market economies.
spread in epidemic proportions. Cardiovascular and cerebrovascu-
lar diseases have emerged as major
Challenges for the future contributors to morbidity and mortal-
ity in many countries of the Region.
If health authorities vigorously com- In India it is estimated that every year
bat infectious diseases such as diar- almost 800 000 people die from coro-
rhoea, acute respiratory infections, nary heart disease and more than
malaria and vaccine-preventable dis- 600 000 from stroke.
eases, a reduction in infant and over- The death rate from cancer is
all mortality can be achieved. The rather consistent in some countries
countries which are in the early stage in the Region where data are avail-
of the epidemiological transition are able, at around 37-38 per 100 000
Bangladesh, Bhutan, most of the population per year. This is lower
states in India, Maldives, Myanmar than in industrialized countries,
and Nepal. mainly because of the different age
As transition proceeds, the infec- structure of the populations, but it
tive component is gradually replaced means that more than 1000 persons
by non-infective and noncommuni- die every day of cancer. Due to lack
cable conditions such as cardiovascu- of good palliative care in most in-
lar diseases, cancer and congenital stances, they die with unbearable
anomalies, endocrine disorders and pain and suffering, for patients and
accidents. This is the situation in the families alike.
185
The World Health Report 1998
27 Member States
1 Associate Member
Population (1997): 1 634 million
GNP per capita
Regional average (1995) $ 4 253
min.: Viet Nam $ 240
max.: Japan $ 39 640
Annual average growth rate
(1985-1995)
min.: Mongolia -3.8 %
max.: China 8.3 %
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187
The World Health Report 1998
Death rates: age- and sex-standardized, and age-specific, tives in most countries and areas to
1955-2025 estimates (per 100 000 population) strengthen individual and community
participation in development. Coun-
Age group 1955 1975 1995 2025 tries in the Region are at different
stages of the health transition.
Age- and sex-standardized 2 150 826 725 510
Cambodia, the Lao Peoples
0-4 5 768 1 364 926 343
Democratic Republic, Papua New
5-19 681 149 87 31
Guinea and some smaller Pacific is-
20-64 1 272 452 371 346
land countries all have segments of
65+ 8 695 5 665 6 058 5 298
the population at the early stage of
the health transition, experiencing in-
programming, evaluation and infor- In the 1990s, a stronger emphasis fectious diseases, high maternal mor-
mation support. Most activities fo- was placed on the six regional priori- tality ratios and infant mortality rates.
cused on strengthening or reorienting ties development of human re- Fiji, Malaysia, the Federated
primary health care through training, sources for health, eradication or con- States of Micronesia, Mongolia, the
operational studies and technical ad- trol of selected diseases, health pro- Philippines, rural areas of China and
vice. The objective was the integrated motion, environmental health, ex- Viet Nam include populations in the
delivery of health services, especially change of information and experience middle stage of the health transition,
in the areas of maternal and child and strengthening management. A who experience a comparatively high
health, immunization, diarrhoeal dis- seventh regional priority control of incidence of communicable diseases
ease control, water supply and sani- emerging and re-emerging commu- and maternal morbidity, while at the
tation. However, most countries still nicable diseases was added in 1996. same time suffering strokes and a
had to address inappropriate training Considerable progress was made variety of cancers.
and deployment of staff, inadequate towards the eradication of selected Considerable progress was made
patterns of service and low quality of diseases. Supplementary immuniza- towards the eradication of selected
maternal and child health and family tion with the aim of eradicating po- diseases. Supplementary immuniza-
planning services. liomyelitis began in 1992, and in the tion with the aim of eradicating po-
Malaria prevention and control period from 1993 to 1997 approxi- liomyelitis began in 1992, and in the
deteriorated in a number of countries mately 100 million children were im- period from 1993 to 1997 approxi-
owing to administrative difficulties or munized each year in a series of na- mately 100 million children were im-
lack of resources. Leprosy pro- tional and subnational immunization munized each year in a series of na-
grammes were integrated into general days and high-risk response immuni- tional and subnational immunization
health services and there was a gen- zation initiatives. days and high-risk response immuni-
eral improvement in leprosy case- The annual incidence of tubercu- zation initiatives.
finding. Improved programmes led to losis did not decline, although the As demonstrated by the marked
a significant decline in mortality and mortality rate fell. The resurgence of decline in diseases attributable to
morbidity due to tuberculosis. How- malaria continued to pose problems. poor water quality and sanitation, the
ever, there was a general increase in The control of other diseases such as Region has achieved many collective
the incidence of sexually transmitted acute respiratory infections and goals in environmental protection.
diseases, especially gonorrhoea. Com- diarrhoeal diseases made consider- For the majority of developing coun-
munity participation and health edu- able progress. AIDS prevention and tries, efforts focus on the emerging
cation were key components in the control programmes were established physical hazards associated with
provision of safe drinking-water and in most countries and areas. chemicals, air pollution and large con-
adequate sanitation. Pollution and struction projects. Community sani-
food safety problems were emerging. Current situation tation and waste management are
The Regional Office has provided ex- high priority concerns in most island
pertise for industrial waste effluent Since 1991, two primary trends have states.
control, water quality monitoring influenced health policies in the Re- Human resources are often con-
management and environmental gion: the evolution of new organiza- centrated in urban areas where con-
monitoring. tional structures in the former cen- ditions of work are usually better. In
trally-planned economies and initia- some countries, critical nationwide
188
WHO worldwide
Leading clusters of diseases/conditions, Western Pacific Region, There is no unique solution that
selected years (indicative list) will achieve the best results in every
situation. Nor is there even any ideal
Disease category 1960 1980 1997 2025 solution that can be foreseen. The re-
newal of health for all framework is a
Infectious and parasitic
guide for setting directions and an
Perinatal and maternal
attempt to highlight the most signifi-
Malignant neoplasms 3 2 2 2
cant issues.
Endocrine and nutritional
Mental and behavioural
The next step is to develop imple-
Circulatory system 2 1 1 1 mentation plans for the movement
Respiratory system 1 3 3 4 from policy to action. The implemen-
Digestive systema 5 5 5 5 tation of policies in the 21st century
All external causes 4 4 4 3 calls for close monitoring, further re-
a
Category used by Western Pacific Region only. finement and development of appro-
priate, useful and relevant indicators.
It also calls for implementation to take
public service downsizing measures burden of traditional communicable place through an appropriate infra-
are being implemented with conse- diseases and other conditions that structure, which includes standards,
quent effects on distribution of the typically affect young children. How- guidelines, workforce development
workforce. Shortages of skilled work- ever, it is apparent that this new pros- and technical support.
ers continue to be a concern in many perity has also led to many new influ-
island countries. ences that have the potential to re-
Some of the most interesting and duce the quality of life.
challenging recent developments re- Individuals and communities will
late to the promotion and support of have a greater role, while the influ-
new structures for the delivery of health ence of governments will be less per-
services (China and New Zealand). vasive.
One of the more significant efforts The epidemiological transition is
in most countries in the Region is the one long-term trend directly influenc-
strengthening and realigning of ing the needs of the health sector. The
health promotion programmes to other is demographic changes, and in
meet the challenges posed by emerg- particular, the significant rise in the
ing health conditions associated with number of people living beyond 65
lifestyle and individual behaviour. years.
The health sector in the 21st cen-
Future trends tury will face three major challenges.
First, there is a need to ensure that
The primary health care approach as all citizens enjoy equal access to
a fundamental value for health poli- health care. In a market-oriented
cies will remain valid into the 21st economy, special attention will be
century. However, a number of domi- needed to ensure that health care is
nant themes are emerging, including accessible for those unable to pay. The
the use of more comprehensive second major challenge concerns the
frameworks for planning new struc- provision of quality care. The issue of
tures for the delivery of care and the quality also applies to the best and
involvement of the community. most appropriate care given for acute
Rapid economic growth in the conditions. The third major challenge
majority of countries in the Region is that of costs. The health industry is
has provided most communities with very labour-intensive, so its costs will
significant improvements to their typically increase more rapidly than
quality of life and has reduced the costs in the economy as a whole.
189
Global partnerships for health
Chapter 7
Global partnerships for health
Traditional partners WHO has closely coordinated its
activities with the United Nations
R
elations with the United since 1948, including for example in
Nations and other intergov- the area of personnel management,
ernmental bodies are the re- in order to establish a single, unified
sult of formal agreements which call international civil service, or in rela-
for ratification by a two-thirds ma- tion to the major international con-
jority of the World Health Assembly. ferences and their follow-up. Since
From the outset, these agreements 1949, WHO has played an important
WHO has closely made provision for reciprocal repre- role within the international drug
sentation at meetings, the establish- control system of the United Nations
ment of joint committees for special based on the advice of the Expert
coordinated its purposes, the exchange of informa- Committee on Drug Dependence,
tion and the coordination of statisti- which evaluates individual psycho-
cal services. In 1965, 1971 and 1994, active substances and recommends
activities with the the general programmes of work of appropriate control measures. The
WHO highlighted the importance modalities for collaboration are now
of the health element in national so- being reviewed as a result of the new
United Nations cioeconomic development and of reform package launched in 1997 by
coordination with other organiza- the Secretary General of the United
tions work in health, to make opti- Nations. Several aspects of the pro-
since 1948. mum use of all resources available. posed package have implications for
In order to coordinate the activities WHOs work since it addresses the
of the specialized agencies, the Ad- whole spectrum of development is-
ministrative Committee on Coor- sues, including emergency response
dination (ACC) was set up in 1949, programmes. The danger of overlap-
composed of the Secretary General ping and duplication continues to ex-
of the United Nations and the ex- ist, at both global and country levels,
ecutive heads of the specialized with respect to WHOs mandate to
agencies. In response to the con- direct and coordinate international
cerns of Member States for the fol- health work, in the light of the grow-
low-up of the major United Nations ing involvement of organizations of
conferences in the 1990s, the ACC the United Nations system in health.
established three time-limited The United Nations system-wide
interagency task forces, a prominent Special Initiative on Africa, within
theme of which is the alleviation of which health and education are pri-
poverty, with health being a central ority components, provides an oppor-
issue. WHO has been particularly tunity to reinforce collaborative activi-
active in that forum, bringing health ties with the Organization for African
issues to the centre of the debate Unity, the Economic Commission for
and seeking cooperation for the re- Africa, the African Development
newed health-for-all policy and up- Bank and African regional economic
dated strategies. communities. A WHO working group
191
The World Health Report 1998
on continental Africa was established graphical information systems, has
in 1994 to facilitate WHOs contribu- improved monitoring and manage-
tion to the implementation of the ment of public health programmes
United Nations New Agenda for the established for dracunculiasis, on-
Development of Africa. chocerciasis, African trypanosomiasis,
From the outset WHOs closest trachoma elimination, and tetanus
collaboration has been with UNICEF. immunization. National public health
The First World Health Assembly atlases have been developed which
recommended that the health allow for a comprehensive and dy-
projects financed by UNICEF should namic review and assessment of
be established by mutual agreement multisectoral issues in individual
between the two bodies and their im- countries. They will soon be available
plementation regulated by a Joint on CD-ROM and on Internet.
Committee on Health Policy, which The Joint Committee on Health
consists of representatives of the Ex- Policy is currently being expanded to
ecutive Boards of the two organiza- include UNFPA and has been accord-
tions. In 1949, the principles that ingly renamed the WHO/UNICEF/
From the outset should govern the cooperative rela- UNFPA Coordinating Committee on
tionship between WHO and Health.
UNICEF were defined. UNICEFs WHO was closely associated with
WHOs closest role in health programmes was to fur- the International Labour Organi-
nish the required supplies and serv- zation (ILO) during the 1950s, for
ices, while WHO would study and example in the establishment of the
collaboration has approve plans for all health pro- International Anti-Venereal-Disease
grammes for which countries may Commission of the Rhine, other as-
require supplies from UNICEF. At pects of the hygiene of seafarers and
been with UNICEF. the end of the 1950s, WHO provided occupational health, and the medical
the international health personnel examination of migrants.
and UNICEF the supplies. Projects UNESCOs programme of funda-
ranged over practically every field of mental education (combined with
interest to child health e.g. the cam- community development) included
paigns for BCG vaccination, the pro- the study of subjects of direct inter-
gramme for the supply of streptomy- est to WHO, e.g. school health, health
cin and malaria projects, to which training for teachers, and teaching of
were later added projects on mater- social sciences. Other traditional sub-
nal and child health, nutrition (in as- jects of collaboration were the medi-
sociation with FAO), environmental cal aspects of research conducted at
sanitation, aid to hospitals, and milk high-altitude research stations and
hygiene. the use of radioisotopes. The Coun-
One example of a current activity cil of International Organizations of
exploiting modern technology is the Medical Sciences (CIOMS) is a special
WHO/UNICEF joint programme on body set up under the joint sponsor-
data management and mapping for ship of UNESCO and WHO, mainly
public health (Health Map), originally for the coordination of medical sci-
established to provide support to na- ence congresses.
tional programmes for monitoring Cooperation with the Food and
dracunculiasis eradication activities. Agriculture Organization (FAO)
The scope of its activities has now concentrated on work in nutrition and
been extended to support other dis- the zoonoses. Joint expert committees
ease control activities. This service, have examined these and related sub-
through the use of mapping and geo- jects such as the use of food additives,
192
Global partnerships for health
milk and meat hygiene, and their rec- Bretton Woods institutions, the IMF
ommendations have been the basis and the World Bank. Although they
for joint FAO/WHO activities nu- played only a subordinate role in the
tritional surveys, training courses, first postwar decade, they repre-
seminars and coordination of research sented a depoliticized way of dealing
programmes. Since 1962, WHO has with economic issues. Since the
implemented the FAO/WHO Food WHO/World Bank review meeting
Standard Programme, through the held in 1994, systematic collaboration
Codex Alimentarius Commission, activities have been developed at the
whose objective is to protect the country level and are reflected in the
health of consumers while facilitating Banks 1997 publications. The Bank
trade in food. Since 1995, and the for- adopted the idea of WHO partner-
mation of the World Trade Organiza- ship in health development. Two key
tion, the Codex standards are the forms of collaboration are required:
global benchmarks or international country-level collaboration in which
reference values for food safety WHO technical expertise is mobilized Since 1995,
(see Box 5). to improve the design, supervision
Other traditional cooperative ac- and evaluation of Bank-supported
tivities were, for example, with ICAO projects; and global collaboration in and the formation
concerning the disinsecting and dis- which WHO and the Bank join forces
infection of aircraft, international to advance international understand-
quarantine, and hygiene and sanita- ing of health, nutrition and popula-
of the World Trade
tion of airports; and with ITU, on tion issues.
matters of notification such as epide- In 1996, a new joint United Na- Organization,
miological radio bulletins, as well as tions Programme on HIV/AIDS
on certain aspects of the hygiene of (UNAIDS) was launched, cosponsor-
seafarers. WHO was in touch with the ed by UNDP, UNESCO, UNFPA, the Codex standards
Universal Postal Union (UPU) at dif- UNICEF, WHO and the World Bank.
ferent times with regard to the trans- Its objectives are to foster an ex-
port of dangerous goods, including panded national response to the epi- are the global
therapeutic substances and insecti- demic, to promote strong commit-
cides, and delays in the shipment of ment by governments to an expanded
perishable biological and pathologi- response, to strengthen and coordi- benchmarks.
cal materials due to variations in na- nate UN action against HIV/AIDS at
tional postal regulations. the global and national levels, and to
Examples of activities conducted identify, develop and advocate inter-
in 1997 with WHOs traditional part- national best practice.
ners include: community-based reha- WHO works with the five major
bilitation programmes (with ILO, regional development banks, con-
UNESCO and UNICEF); program- centrating on regional health sector
ming for adolescent health (with policy formulation and on country-
UNFPA and UNICEF); and caring specific support. Closer links have
for the nutritionally vulnerable dur- also been formed with regional inter-
ing emergencies (with UNHCR). governmental organizations and re-
Since 1945, a large number of in- gional political groupings such as the
stitutional mechanisms have been Organization of African Unity, the
evolved to reconcile the desire for an African Economic Community, the
international economic order with the Southern African Development
domestic concerns and priorities of Community, the Organization of
States. The most general channels of American States, the Association of
cooperation were the so-called South-East Asian Nations, the African,
193
The World Health Report 1998
Union. There is much that WHO and
Box 29. Diabetes longstanding cooperation between the Union can do together. Exchange
WHO and IDF of information, cooperation on par-
ticular issues and eventually in joint
programmes are only a start. The
The International Diabetes Federation (IDF) has been in official relations with
mandates given to both organizations
WHO since 1957. In 1962 WHOs Executive Board adopted a resolution
by their shared Membership call for
drawing attention to the public health importance of diabetes mellitus and
the establishment of a close partner-
calling for action to combat it.
ship in Europe (where WHO can be
In response, the first WHO Technical Report on the subject of diabetes
proactive in conceptual developments
was published in 1965. The second WHO Expert Committee on Diabetes
and linkages with the international
met in 1979, following which ties between WHO and IDF were strengthened,
scientific community) and in devel-
and a network of collaborating centres was established, now numbering 30.
oping countries, where WHO pro-
WHO and IDF have collaborated on many issues relating to diabetes,
vides a framework and often a chan-
including standardization, national action plans, patient education, insulin
nel for health programmes initiated
provision, and improving diabetes care at the primary level. A WHO study
through bilateral and regional agree-
group on diabetes which met in 1985 recommended such collaboration at
ments. An example of a joint activity
regional level, and this has been the trend since. One important example was
in 1997 was the convening of a work-
the joint IDF and WHO Regional Office for Europe meeting in 1989 which
ing group on cross-border advertis-
issued the Saint Vincent Declaration, aimed at stimulating activity in Europe
ing, promotion and sale of medical
to improve the life and health of people with diabetes. Recently, a similar
products through the Internet, which
declaration has been adopted for the Americas.
among other specific technical rec-
World Diabetes Day (held on 14 November each year since 1991) is
ommendations aimed to encourage
cosponsored by IDF and WHO and has a special theme each year. The theme
the international community to for-
in 1996, the 75th anniversary of the discovery of insulin by Frederick Ban-
mulate self-regulatory guidelines for
ting (whose birth date was 14 November) and Charles Best in Toronto in
good informational practice, consist-
1921, was Insulin for life: 75 years of insulin.
ent with the principles of the WHO
In 1997 the theme was Global awareness: our key to a better life.
ethical criteria for medicinal drug
About half the people worldwide who have diabetes are unaware of their
promotion.
condition although they are prone to develop serious complications. The com-
To be eligible for admission to
plications of type 2 (non-insulin-dependent) diabetes are potentially lifethreat-
official relationship with WHO, a
ening and as serious as those of type 1 (insulin-dependent) diabetes, a fact
nongovernmental organization
that is often overlooked. The emphasis in 1997 was on creating increased
(NGO) must be concerned with mat-
awareness among the general public of the causes, symptoms, treatment
ters within WHOs competence and
and complications of diabetes, so as to encourage prevention, earlier diag-
pursue aims and purposes in con-
nosis and improved health care.
formity with the spirit, purposes and
Approximately 140 million people in the world today have diabetes, and
principles of the WHO Constitution.
many of them need insulin, which is designated as an essential drug by WHO.
The NGO must be of recognized
However, for various reasons, insulin is not always available to or affordable
standing and represent a substantial
by those who need it for survival or for adequate metabolic control. To over-
proportion of the persons organized
come this problem will require the combined efforts of governments, WHO,
for the purpose of participation in the
IDF, diabetic associations and industry.
particular field of interest in which it
operates. It must have a directing
body and authority to speak for its
Caribbean and Pacific Group of members through its authorized rep-
States and the League of Arab States. resentatives. An NGO admitted to
Since the 1950s, cooperation official relationship is entitled to ap-
between European nations has ex- point a representative to participate,
tended to a number of areas, and without right of vote, in WHO meet-
progress towards unification has led ings and, on the invitation of the
to the emergence of the European Chairman, to address the meeting on
194
Global partnerships for health
an item in which it has a particular to WHO and given added impetus to
interest. They fall into two main cat- its mandate and its constitutional role
egories: those engaged in some par- as directing and coordinating author-
ticular branch of medical science or ity in international health work.
research (Box 29) and those repre- New avenues for collaborative
senting a more general interest. work have opened up, making it es-
In 1997, the decision of the Ex- sential for WHO to strengthen its
ecutive Board to admit an additional leadership role and provide a dynamic
five NGOs into official relations with orientation of cooperation towards
WHO brought their number to 188. global partnership and burden-shar-
These help to illustrate the scope and ing. As governments and donor coun-
variety of this longstanding type of tries are increasingly concerned to get
collaboration. The International As- good value for money on their invest-
sociation for Dental Research has ments in health, balanced health
helped WHO to assess future oral funding by bilateral and multilateral
health research needs, while the institutions has become a vital issue. New avenues for
World Federation of Chiropractic has In 1984, a collaborative agree-
participated in the development of ment was established between WHO
guidelines on the prevention and and the International Olympic Com- collaborative work
management of neuromusculo- mittee (IOC) to promote sport and
skeletal disorders in occupational physical activity through the pro-
health. ORBIS International, which gramme Winners for health, linking
have opened up,
works to fight blindness through edu- sport with health-for-all goals. Since
cation and practical training for oph- 1988, WHO has endorsed the organi- making it essential
thalmologists, nurses, biomedical zation of smoke-free Olympic games.
technicians and health care workers, Another example of linking physical
supports WHO efforts to assess glo- activity, sport and health is the global for WHO to strengthen
bal trends in blindness, and at the initiative on active living launched in
national level contributes to improv- cooperation with a group of partners
ing skills. The International Associa- such as the IOC, UNESCO, the its leadership role.
tion for the Scientific Study of Intel- International Federation of Sports
lectual Disabilities is contributing to Medicine, and Rotary International
the revision of the ICD, and Inclu- among many others. WHO collabo-
sion International, composed of the rating centres on health promotion in
intellectually disabled and their fami- Finland, Japan, the United Kingdom
lies, friends and advocates, will be and the United States have also been
contributing to the evaluation of the involved. Less traditional partners are
new International Classification of also being sought, such as for exam-
Impairments, Activities and Partici- ple the initiative launched in 1997
pation (see Box 21). with the organizers of EXPO 2000,
concerning Health futures (Box 30).
Partners today Broad-ranging partnerships are
increasingly being set up to target
The multifaceted nature of health and specific health problems. For exam-
the multisectoral interactions that in- ple, to achieve polio eradication, a
fluence it have induced an increasing global partnership was formed with,
number of organizations, within and among others, ministries of health in
outside the United Nations system, to polio-endemic countries, Rotary In-
become active in the health field. ternational, UNICEF, the Govern-
These new partners on the health ments of Australia, Canada, Den-
scene have brought new challenges mark, Japan, the United Kingdom
195
The World Health Report 1998
and the United States, as well as in the provision of emergency assist-
NGOs. An estimated $1 billion of ex- ance by the United Nations system.
ternal funding is needed until final Emergency relief, disaster prepar-
eradication. The very success of the edness and management of disasters
venture, which has resulted in dimin- are the three main lines of action for
ishing threats from vaccine-prevent- WHOs involvement. Emergency hu-
able diseases, is in danger of being its manitarian action is made possible
downfall, as the public and donors through funding from donors as
tend to lose interest when the diseases extrabudgetary contributions ($25
come under control. But experience million in 1996). The Panafrican
shows that the diseases return as soon Emergency Training Centre and the
as vaccine coverage drops. Emergency Health Management
Training project based in Addis Ababa
Partners in response provide support to countries of the
African continent. In the Americas,
Under WHOs to emergencies the Regional Emergency Programme
The traditional forms of action in re- has strengthened the capacity of
emergency managers to coordinate
impetus, several sponse to emergency situations, due
with the national health sector, and
to natural or other disasters, originally
consisted mainly of immediate aid in to this end developed a computerized
relief supply management system. In
universities have the form of urgently needed drugs,
South-East Asia, the national capaci-
vaccines, medical equipment and
other medical supplies. In the 1970s, ties of Member States and their co-
established however, WHO and the international ordinating mechanisms were rein-
community emphasized and devel- forced, especially in Bangladesh,
oped primary health care approaches India and Myanmar. At the global
undergraduate and and, more recently, relief pro- level, several sets of guidelines were
grammes focusing on preventive pro- issued and training programmes were
grammes. Technical cooperation with implemented.
postgraduate disaster-prone countries increasingly The new WHO policy for emer-
aimed at improving national capacity gency and humanitarian activities is
to take preventive measures and to based on three concepts:
programmes on remain more effectively in control of the Organizations position as a
196
Global partnerships for health
WHO is planning to take millions of people on a fascinat- tively or adversely, and to encourage people to protect
ing journey to discover Health Futures, an exhibition pre- and promote their health more actively in various ways.
senting its vision for healthy living in the 21st century. Visitors will learn that health and well-being are the
The exhibition is being developed in cooperation with the product of many factors, and that good health needs sup-
organizers of EXPO 2000, the World Exhibition set to portive environments; that given supportive environments,
celebrate the third millennium in Hanover, Germany, from people have the power to improve their health; and that
1 June to 31 October 2000. new knowledge and technologies are revolutionizing ap-
In 2000, the theme will be the future itself under the proaches to health, health care and health systems. Ar-
banner Humankind Nature Technology. EXPO 2000 eas to be highlighted are youth and active ageing, infec-
aims to stimulate peoples imagination, and encourage tious and chronic diseases, healthy cities and technology
them into actively meeting the challenges facing human- for health. The exhibition will illustrate realistic, practical,
kind on the eve of the 21st century. The United Nations cost-effective and sustainable approaches that are avail-
programme of action for sustainable development which able now or will be in the near future.
resulted from the 1992 Earth Summit in Rio de Janeiro, Based on WHOs new policy for health for all in the
Brazil, will provide the framework for the many events at 21st century, the exhibition will underline the major de-
EXPO 2000. In the Thematic Area, Agenda 21 will be terminants of health ranging from nutrition to the empow-
brought to life in several subexhibitions: health, human- erment of women and will remind visitors of the equity
kind, environment; landscape and climate, nutrition, knowl- gap in health care, and of the gap in life expectancy at
edge; information and communication, the future of work, birth between developing and developed countries, stress-
energy, mobility, basic needs, the future of the past and ing the need for international cooperation to eliminate or
the 21st century. eradicate infectious diseases.
WHO will develop Health Futures as part of the The- Health Futures will explore the effectiveness of mod-
matic Area, highlighting the health chapter of Agenda 21, ern media to communicate complex health messages to a
which underlines that health and sustainable development mass lay audience, combining theatre stage productions,
are inextricably linked. Health Futures will make clear that science centre approaches and multimedia messages to
the promotion and protection of health are crucial to sus- form an innovative learning experience. Educational me-
tainable development. Reaching millions of Expo visitors, dia envisaged include CD-ROMs, electronic games, health
the health exhibition is a unique opportunity to promote on-line systems, and an Internet site including a virtual
public awareness of the factors that influence health, posi- walk through Health Futures.
197
The World Health Report 1998
fertility regulation; and generation of sumed influential positions in minis-
a wealth of new data related to the tries of health and elsewhere, and
development of immuno-contracep- have introduced significant manage-
tives. In the area of evaluation of the rial, technical and political changes in
safety and efficacy of methods of fer- the research and control of tropical
tility regulation, it has published find- diseases.
ings of global importance on the re- Since 1994, research on each of
lationship between hormonal contra- the eight diseases has been carried
ceptives and cancer, and oral contra- out in three broad cross-cutting areas:
ceptives and cardiovascular disease. strategic research, product research
Studies conducted by the Programme and development, and applied field
have assessed, among others, the be- research. The emphasis in 1997 was
havioural determinants of choice of on identifying and developing new
family planning methods and issues drugs, improving the use of existing
surrounding gender, sexuality and re- drugs, improving drug distribution,
Some 1700 production. mass chemotherapy, community-
The programme currently relies directed treatment, vaccines, genome
on a global network of over 100 cen- studies, rapid assessment methods,
scientists in tres for the conduct of much of the vector control, or in some instances,
research it sponsors. These centres more efficient diagnosis. Challenges
help to guide and evaluate the pro- include: development of drug and
developing countries grammes work, conduct nationally pesticide resistance; high costs of
relevant reproductive health research drug development; social and eco-
have been trained and participate in the global research nomic constraints in disease endemic
effort. Some 1700 scientists in devel- countries; problems in drug delivery;
oping countries have been trained in changing patterns of land use; lack of
in various disciplines various disciplines associated with research capacity in developing coun-
human reproduction research, and a tries; and negative gender attitudes
collaborative relationship has been towards women. In research, many
associated with fostered with a large number of sci- leads ultimately come to nothing, de-
entists in the reproductive health spite their early promise. There have
community. also been disappointments, particu-
human reproduction A special programme for research larly in the field of drug development.
and training in tropical diseases was Some products, although useful, need
established in 1975 by WHO together further improving, e.g. eflornithine
research. with UNDP and the World Bank. It (for the treatment of advanced cases
was concerned with eight diseases for of African trypanosomiasis) is still pro-
which the situation was worsening: hibitively expensive and costs much
malaria, schistosomiasis, lymphatic more than patients in endemic coun-
filariasis, onchocerciasis, Chagas dis- tries could ever afford. Most needed
ease, leishmaniasis, African trypano- are more funds; novel ways of collabo-
somiasis and leprosy. In the 22 years rating with industry and strengthen-
since its creation the special pro- ing product research and develop-
gramme has put more than 30 prod- ment in developing countries.
ucts into use (including drugs, diag- In 1990, the World Health Assem-
nostics and vector-control tools), and bly called on Member States to un-
has approximately 30 more (includ- dertake essential health research ap-
ing vaccines) in the pipeline. The propriate to national needs and
training of more than 900 scientists strengthen national research capabili-
from developing countries has been ties. In 1994 the Advisory Commit-
supported. These trainees have as- tee on Health Research and
198
Global partnerships for health
CIOMS organized a landmark meet- stitutional strengthening efforts de-
ing on the impact of scientific veloped under WHOs leadership at
advances on future health. The all levels.
ACHR has now prepared a research The WHO Centre for Health
agenda to complement and support Development, established in 1996 in
the WHO policy and strategy for Kobe (Japan), is fully financed from
health for all in the 21st century. It extrabudgetary resources provided by
reviews evolving problems of critical a Japanese consortium. The Centre
significance to health, and suggests collects, analyses and disseminates in-
ways of harnessing the power of sci- formation, and carries out interdisci-
ence, technology and medicine to plinary and multisectoral research to
contribute to problem solution. It is identify ways of integrating health in
not limited to conventional biomedi- international and national policies. It
cal research or the health sector, but will also provide training for health
rather addresses all disciplines and all leaders in different areas of research
fields of research that can contribute methodology and international public In 1995 the World
to human health. WHOs role is to fa- health. The priority areas of research
cilitate the networking of the research selected as an initial programme for
community so as to bring the power the Centre are progressing urbaniza- Health Assembly
of scientific knowledge, research and tion and the ageing of societies.
technology to bear on global health
called for a global
development. Partners for the future
The Second World Health Assem-
bly (1949) laid down the policy that In 1995 the World Health Assembly consultative process
the Organization should not consider called for a global consultative proc-
the establishment, under its own aus- ess that would involve the widest range
pices, of international research insti- of partners, starting with Member that would involve
tutions, and that research in the field States, in order to develop a new glo-
of health is best advanced by assist- bal health policy for the 21st century.
ing, coordinating and making use of The consultative process since then the widest range
the activities of existing institutions. has involved extensive and detailed
All WHO collaborating centres, analyses of successes and future chal-
whether they deal with research or lenges in most countries of the world. of partners to develop
not, have been designated under that During 1997, several global and re-
policy. Thanks to their permanent gional meetings identified how coun-
linkages with technical and scientific tries could work better together to a new global
institutions in the countries, these achieve health for all. Selected global
centres contribute to the develop- meetings that brought together inter-
ment of new areas and types of health national experts and a diversity of in- health policy for the
research at country level, and to the puts in 1997 included a consultation
application of the results of research with CIOMS on ethics, equity and
and the transfer of new technology to human rights in a meeting on
21st century.
the national network of institutions. intersectoral action for health,
The large increase in the number of cosponsored by the Canadian, Swed-
centres in the course of the last three ish and Finnish governments; a formal
decades has been due mainly to the consultation with 130 international
development of the research compo- nongovernmental organizations; and
nent of WHOs programme. The a critical assessment of impediments
WHO collaborating centres are and challenges to the development of
therefore the keystones of the col- sustainable health systems. A draft
laborative research capacity and in- policy was reviewed by WHOs gov-
199
The World Health Report 1998
erning bodies in 1997. The consulta- societies and individuals for the infor-
tion has extended beyond government mation age. Coming to terms with the
and health ministries to consider the knowledge revolution is a central part
views of nongovernmental organiza- of rethinking development for the
tions, United Nations partners (includ- 21st century.
ing the World Bank and the World The global knowledge revolution
Trade Organization), the private sec- has only just begun and we are still at
tor, and academic and research insti- the dawn of the information age, but
tutions. Hundreds of individuals and we are already faced with a series of
organizations have been mobilized in urgent riddles and challenges.
the process. Their views have been sys- Many individuals and probably
tematically analysed and are reflected the world as a whole will benefit from
in the new health policy, Health for all new technology. However, if left on
in the 21st century, to be submitted to its present track, the revolution will
the 51st World Health Assembly in probably bypass billions of people. No
WHO is participating May 1998. one actor alone has the combination
The Global Knowledge Partner- of power, resources and vision neces-
ship, which includes all the major sary to guide the revolution so that it
in the multilateral United Nations agencies, is currently advances the general good, neither
preparing an inventory of current the governments, the private sector,
development of knowledge for development activi- civil society nor the voluntary com-
ties conducted by their respective or- munity. The knowledge revolution
ganizations. WHO is participating in comes at a time when traditional con-
knowledge in the the multilateral development of cepts of international development
knowledge in the global health do- are being questioned. The develop-
main. Global knowledge builds on ing world has fragmented into a ka-
global health domain. what began at the 1995 G7 meeting leidoscope of countries and blocs, and
on the global information society, and old donor-recipient relationships have
continued at the more broadly-based become archaic. Global problems, too
1996 conference on the information big for national governments and in-
society and development. The Global ternational agencies, call for new part-
Knowledge 97 Conference, of which nerships, coalitions and networks ca-
WHO was a partner, was part of a pable of responding at an appropri-
much broader process of preparing ate scale, speed and level.
200
Health agenda for the 21st century
Chapter 8
Health agenda for the 21st century
Future health challenges 65 and above, 14 children under 5 and
more than 40 older children and ado-
D
uring 1995, 15 000 babies lescents aged 5-19 years.
were born every hour. More For young and old alike, the world
than 90% of them will sur- of 2025 will be very different from
vive their first five years to see the that of today. This report has ex-
dawn of the new century. Half of plained trends in health across the
them will live to celebrate their 75th human life span during the past 50
birthday in 2070. Many will become years. While the conclusion overall is
centenarians who will live throughout that health has steadily improved, the
the entire 21st century and into the main issues now are how to sustain
early 22nd. those improvements and how to meet
By 2025, the 1995 baby will be the health challenges of the future.
an adult whose own child will have a In the early 21st century the world,
90% chance of surviving not merely already free of smallpox, should also
the first five years, but the first 50 be free of poliomyelitis, measles, and
years of life. Two out of every three neonatal tetanus. Some other infec-
babies born in 2025 will live to be at tious and parasitic diseases will be
least 75. eliminated, and the burden of many
The enhanced life expectancy of more which currently afflict tropical
tomorrows children is the harvest of regions should be further reduced.
health improvements witnessed in the Most children should be pro-
20th century. Another consequence tected from vaccine-preventable dis-
is that even before 2025, for the first eases through well-established and
time, small children will be outnum- sustainable immunization pro-
bered by people over 65. While chil- grammes; deaths among small chil-
dren under 5 years will represent dren should be further cut through a
about 8% of a global population that package of interventions known as the
will have risen to 8 billion, the over- Integrated Management of Child-
65s will represent about 10%. For hood Illnesses.
every 100 adults aged 20-64 in 2025 Most of the global population
there should be 17 older people aged should have regular access to essen-
tial drugs. However, as shown in
Table 11, it is disconcerting to note that
Table 11. Deaths by age group, world, 1975-2000 and 2000-2025 in the early 21st century, it is expected
1975-2000 2000-2025 that there will be 21% more deaths
among adults aged 20-64 years than
Age group Number Percentage of Number Percentage of
(000) total (000) total during the late 20th century. Given
0-4 304 970 25 181 024 12 that these adults form the main foun-
5-19 96 127 8 63 400 4 dation for any social and economic
20-64 349 719 28 422 028 29 support to the young and old, it is im-
65+ 482 479 39 787 202 54 perative that they are protected from
All ages 1 233 295 100 1 453 654 100 premature mortality and disability.
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The World Health Report 1998
The epidemiological assessment diseases have discussed the dominant
in this report suggests that the major role of these diseases, musculoskel-
health problems by the year 2025 will etal conditions, and mental and be-
be diseases of the circulatory system, havioural disorders, in defining ill-
cancers, infectious and parasitic dis- health among adults. Available data
eases and external causes (Table 12). indicate that in some countries,
Chapter 3 of this report and The deaths from circulatory diseases are
World Health Report 1997 on chronic falling while cancer deaths are in-
creasing (Fig. 21).
WHO estimates that about two-
Fig. 21. Death rates by cause, adults aged 20-64, thirds of global cancer deaths, cancer
selected countries, 1985 and 1995 a incidence during 1997 and cancer
prevalence in 1997 can be clustered
according to just four risk factors, i.e.:
Japan
diet-related (stomach, colon-rectum,
liver, mouth-pharynx and prostate);
Canada tobacco-related (lung); infection-re-
lated (lymphoma and cervix); and hor-
France mone-related (breast). WHO fore-
sees that the overeall global situation
United States of
America in respect of cancers of the stomach,
liver, mouth and pharynx, and of the
Cuba cervix and breast, will improve in the
early 21st century while those related
Austria to the lung, trachea, bronchus, colon
and rectum, and prostate as well as
Portugal lymphoma, will worsen.
The changing world is experienc-
ing changing patterns of health. In-
Kuwait
fluences include: rapid moderniza-
tion; an everyday life dependent on
Poland
technological advances; changing be-
haviour sedentary living, excessive
Russian Federation or ill-balanced diets and smoking;
and a deteriorating environment air
China (urban) pollution, exposure to chemicals, con-
tamination of soil and water, and haz-
China (rural) ards to food safety. Together, these are
LYT 98030
202
Health agenda for the 21st century
1960 1980
Disease category Africa The Eastern Europe South-East Western Africa The Eastern Europe South-East Western
Americas Mediterranean Asia Pacificb Americas Mediterranean Asia Pacificb
1997 2025
Disease category Africa The Eastern Europe South-East Western Africa The Eastern Europe South-East Western
Americas Mediterranean Asia Pacificb Americas Mediterranean Asia Pacific b
203
The World Health Report 1998
Because of the importance of the brain in controlling hu- such as dyslexia, epilepsy and motor dysfunctions. These
man activity, injury and diseases affecting the brain result tools should also throw light on how the brain is altered
in a significant proportion of all human disability. Until rela- during the disturbed thought patterns and emotions that
tively recently, knowledge about the brain depended on are such a troublesome feature of schizophrenia and the
crude observation and studying the effects of head injury. affective disorders.
Study of the brains electrical activity gave some insight Another factor influencing our understanding of the
into the pathology of epilepsy, but only in recent decades relationship between brain function and mental function is
have scientific studies thrown light on the relationships the discovery in recent decades of the psychotropic drugs
between brain function and mental functions such as used to treat mental disorders. These drugs have shown
thought and emotions. The coming decades should bring that it is possible to change mental function by chemically
better understanding of the biological or physical proc- modifying brain function. Study of their action has led to
esses in the brain that accompany thinking and feeling. an understanding of the chemicals that carry messages
Until recently, the physical processes of the brain were from one nerve cell to another (neurotransmitters) and
studied by neurologists and neuroscientists, whereas the the chemical environment in which the brain functions.
mental processes (thinking and feeling) were studied by Originally, most of the drugs used to treat mental disor-
psychologists and psychiatrists, with little interaction be- ders were discovered almost by chance. Now, with more
tween the two groups. In some countries, the clinical dis- precise knowledge of neurotransmission, it is possible to
cipline of neuropsychiatry has flourished, bringing the two design drugs that will block or accelerate the nervous ac-
together, while in others they have stayed separate. Sev- tivity causing mental disorders. It is now unscientific to
eral factors are now bringing the two together. One is the argue over whether epilepsy, stroke, dementia, multiple
advance in noninvasive methods of investigation. Apart sclerosis, schizophrenia, bipolar disorders or indeed the
form crude electroencephalographs, the only way of in- addictions are neurological or psychiatric. All are dis-
vestigating brain function used to be to open the skull and eases or conditions of the brain which demand investiga-
physically probe into the brain. The technology is now avail- tion, treatment and care for those affected and, taken
able, however, to localize extremely accurately virtually together, which contribute to an enormous amount of dis-
every part of the brain without opening the skull. By fol- ability in the world.
lowing the changes in blood flow and chemical activity that With increasing knowledge, much of the gulf between
accompany neural activity, it is possible to map the areas the mind and brain, between neurology and psychiatry,
involved when, for instance, the subject looks at some- between neuroscience and psychology, is fast being
thing, hears a word or experiences pain or pleasure. bridged, enabling rational research and interventions to
Within the next 10-15 years, such methods are likely be carried out to prevent or treat brain damage and dis-
to generate new knowledge of the functional anatomy of orders of brain function. These advances have the poten-
the human brain, making possible a better understanding tial to bring about a significant reduction in the level of
of how normal brain function is disturbed in conditions disability worldwide.
brain damage or even allow the brain terventions such as immunization and
to recover completely. For many pa- essential clinical care management,
tients, however, the brain will be irre- personal hygiene, public health and
versibly damaged unless an effective sanitation practices, and the safe
rehabilitation strategy is in place to processing, preparation and handling
make a timely response (Box 31). of foods. With increasing interna-
Globally there are still 21 million tional travel and mass population
deaths among those aged under 50; movements due to war and internal
most of them are due to infectious conflicts, foodborne diseases are
diseases, many of them being pre- emerging as a major threat in the 21st
ventable through cost-effective in- century (Box 32).
204
Health agenda for the 21st century
Globalization of trade and services
also poses global threats to health. Box 32. Foodborne diseases A global threat
The health of the worlds citizens is
inextricably linked, and is less deter- Public health officials attribute the rise in incidence of foodborne illnesses
mined by events within geographical and the emergence of new foodborne diseases to a combination of different
boundaries. The threat posed by factors related to changes in demographics and consumer lifestyles, in food
emerging and re-emerging infectious production, international trade and travel, and microbial adaptation. Globali-
diseases is accentuated by changes in zation of the food supply means that people are exposed, through foods
human behaviour, changes in ecology purchased locally, to pathogens native to remote parts of the world. As a
and climate, in land use patterns and result of international travel, people are exposed to foodborne hazards in
economic development, as well as by foreign countries and import the disease into their home country upon their
tourism and migration. return. As a result, a person may acquire an illness in one country and
Despite the progress that can be expose others in a location thousands of kilometres from the original source
achieved in a world without frontiers, of the infection. Changes in microbial populations can lead to the evolution of
there is a danger that insistence on new pathogens, the development of new virulence factors for old pathogens,
cross-border uniformity, or even on the development of antibiotic resistance making a disease more difficult to
unwarranted minimum levels, could treat, or to changes in the ability to survive in adverse environmental condi-
reduce the scope of mutually ben- tions. People are becoming increasingly vulnerable, particularly since the
eficial trade. Countries may have number of susceptible individuals such as the elderly and people with HIV
failed to enforce adequate environ- infection or other underlying medical conditions is increasing. As lifestyles
mental standards, or (more com- change, more people eat meals prepared outside the home. Insufficient training
monly) been deterred from intro- in food handling constitutes one of the major factors responsible for the rise
ducing justified improvements, by in foodborne disease incidence.
pressures arising from business con- To deal with these problems, a comprehensive strategy is needed at
cerns about international competi- national and international levels. This must be based on effective food con-
tiveness. Attention should be paid to trol, improving agricultural and animal husbandry practices, applying food
identifying those areas of policy technologies with the potential to reduce or eliminate foodborne pathogens,
where common or agreed cross- and educating persons who handle food. Improved surveillance programmes
border minimum standards are jus- are essential for early detection of foodborne disease outbreaks and for lim-
tified, and those where the choice iting their spread before they take on epidemic or pandemic proportions.
should be left to individual States Early identification of the source of the outbreak is becoming increasingly
and governments. important as countries move towards industrialization. Protecting the public
Patterns of health and disease from emerging foodborne diseases also means keeping track of new events
have changed more rapidly world- in agricultural and processing practices and of the origin of food, while cli-
wide in the last half-century than dur- matic and environmental changes need to be monitored for potential nega-
ing any comparable period in history. tive effects on the food chain.
Although survival strategies underly-
ing health systems development dur-
ing the past decades have been ex-
tremely successful in increasing the the health-for-all movement is far
length of human life, they have not from complete.
led to a corresponding reduction in Outlining desirable aspirations for
morbidity and disability, or improve- better health and constructing a rea-
ment in the quality of life. Available sonable vision for the future has be-
data indicate that disability-free life come crucial for setting health objec-
expectancy at birth has not signifi- tives for the early 21st century. It is
cantly increased. While mortality re- therefore time for a breakthrough in
duction targets are achieved through thinking and a clearly defined vision
disease-specific interventions, the for guiding strategies to defeat the
attainment by people of their full po- powerful enemies of positive health,
tential for health the main thrust of and thus ensure quality of life.
205
The World Health Report 1998
Present knowledge and scientific evi- reducing or minimizing adverse
dence show that diseases and disabili- effects of illness and disability, and
ties, which prevent many people from improving quality of life through a
reaching old age in good health, can healthy lifestyle in a healthy
be delayed or avoided. Such preven- physical, social and ecological
tion of major infectious and chronic environment.
diseases is however possible only if The primary concern will be to
there is a shift in emphasis from the improve health potential and qual-
disease itself to risk factors or deter- ity of life at all phases of the life
minants related to the development cycle. Preventive, protective, pro-
of the disease. motive, curative and rehabilitative
A single risk factor may contrib- measures to improve health will
ute to many diseases and different risk also ensure that such improve-
factors often act in combination to ments can be sustained, and if pos-
produce a single disease. Many of sible further enhanced. It will
Many risk factors these risk factors associated with a make individuals economically and
broad spectrum of diseases physi- socially active given their biologi-
cal or mental, infectious or non-infec- cal and chronological maturity.
associated with tious widespread in both develop- The primary objective of health
ing and developed countries have development activities will be out-
been created by, and can be control- come-oriented. Various disease-
a broad spectrum led by people themselves. Tackling a specific interventions will be as-
limited number of risk factors, over sessed not so much in terms of out-
of diseases have been which the individual has control, and puts, for example, improved access
environmental hazards over which to health care or services, reduc-
national and international communi- tion in mortality, morbidity or dis-
created by, and can ties have a say, could reduce substan- ability from any single disease or
tially sickness and suffering caused by condition. Instead they will be as-
them. sessed in terms of outcomes, en-
be controlled by In visualizing the future, the fol- suring value for money by improv-
lowing fundamental points have been ing the overall health of the indi-
considered: vidual and enhancing his or her
people themselves. The primary focus of health devel- health potential. Health care
opment is positive health, an en- should not only meet professional
hancement of the health potential standards but also benefit the per-
of individuals and a contributor to son who receives it. Quality assess-
better quality of life in the context ment may become heavily biased
of human development. Health towards reflecting consumers
will then not be an end in itself but needs and interests as well as their
a resource for everyday life that expectations and values. A major
enables individuals to realize aspi- consequence of such an outcome
rations and strategic needs and to perspective is the advantage of
change or cope with their environ- health and social interventions be-
ment. Policies and strategies for ing integrated and inclusive. It re-
health development provide peo- quires and reflects the contribu-
ple with a positive sense of health tions of all those who provide care
and enable them to make full use including self-care. However, it
of their physical, mental and social cannot identify which specific ini-
capacities. Positive health implies tiative or action was responsible for
adding life to years i.e. increasing the outcome.
years lived free from ill-health,
206
Health agenda for the 21st century
With these fundamentals under-
pinning health improvements for Box 33. Sharing knowledge for health
people-centred development, a fu-
ture health picture can be envisioned A knowledge-based organization in an environment where knowledge has
and elaborated for the first quarter of become a raw material must give serious consideration to how such knowl-
the 21st century. This foresees that, edge is managed, disseminated and used. The interaction between partners
worldwide, every individual should in international health is influenced by the following five key factors:
enjoy his or her full health potential 1. Globalization. Globalization is principally about increasing interdepend-
throughout the life span and be so- ence economic, political and social. It has both positive and negative
cially, economically and mentally pro- influences on health. Integration at one level can be matched by
ductive and able to have a better marginalization and increasing inequities at others.
quality of life. Concerted efforts 2. The information revolution. The rapid development of information and
should be made to sustain and build communications technology opens up new ways to produce, analyse and
on health gains in terms of increased disseminate data and health knowledge. The challenge is to build a man-
life expectancy and reduced risk of ill- aged network that allows accessing and dissemination of knowledge; makes
health, and to reduce and where pos- it useful and practical; and allows for debates and feedback mechanisms.
sible eliminate premature mortality Information technology also makes available new means of assistance
and disability. between centres (telemedicine, Internet-based training, etc.).
An effective response to all these 3. The health research/technology revolution . Health information itself is
challenges requires a radically differ- subject to ever more rapid changes and updates, and WHO information
ent approach and should be based on (for example on drug development, safety, treatment schedules etc.) needs
knowledge, experience and insights to be totally reliable and up to date. The average shelf-life of a health fact
gained over the past 50 years. is currently five years.
Some of the developments in 4. The increased privatization of health, health research and intellectual
technology, and the information and property. Increasingly health and medical research are private, and a
knowledge that stem from them, are determining factor in one of the largest and most rapidly growing world
listed in the following section. So too markets. Research at university institutes is frequently dependent on
are examples of advances in commu- significant contributions from the private sector.
nication technology which allow this 5. A broader understanding of and accountability for health . The increased
information and knowledge to be ac- knowledge available on determinants of health and on the impact of sec-
cessible to those who need it (Box 33). tors other than health calls for a broader range of information input in
areas such as economics, law, human rights and ethics.
Health and technology Reliable health information and knowledge are becoming a sought-after
commodity not only in terms of patents and intellectual property, but also in
The most significant feature of tech-
terms of systems knowledge and comparative data. Given the increasingly
nology development in the early part
fluid borders between health/biomedical research, pharmaceutical and nutri-
of the 21st century will be the rapidly
tion research and agricultural research, the issues and partners WHO deals
increasing knowledge-intensity of
with could change significantly.
products and processes used globally.
The challenge before the international community is how to best manage
Lifelong learning will be essential for
the intellectual capital inherent in these many partners and networks. The
ensuring that workers remain produc-
result of good management of intellectual capital equals health leadership.
tive, especially as populations and la-
The leadership issue in this case is: who sets the gold standard for global
bour forces age over the coming dec-
health issues and the global health debate; and whose approach/paradigm
ades. The emphasis will need to be
on how to define health is accepted. From this follow proposals on how to
on active ageing, encouraging indi-
manage health, pay for health, and measure the health of populations.
viduals to participate fully in society
regardless of their age.
The delivery of health care is de-
pendent on past, recent and future
research in biomedical science. Ex-
amples of the highly successful use of
207
The World Health Report 1998
discoveries in basic science, or tech- though it raises ethical problems, it
nological developments, are: molecu- also has the potential to offer signifi-
lar and cell biology; immunology and cant benefits.
genetics; and those relevant for diag- A wealth of diagnostic devices has
nostic and therapeutic procedures, emerged, covering virtually all
such as magnetic resonance in age- branches of medicine and health care.
ing and the surgical applications of Advances in imaging technology have
laser techniques. In neurobiology, un- brought a new dimension to diagnos-
derstanding of the ever-increasing tic procedures. Ultrasonic techniques
panoply of neurotransmitters has led are cheaper (though less precise) than
to new insights into the action of psy- computer-aided tomography and
chotropic drugs and neurotoxins of magnetic resonance imaging, and are
dietary origin. suitable for screening and fore a wide
Applications of technology can be range of diagnostic work. They also
divided according to functional cat- have therapeutic applications. Endo-
Current ground- egories: for prevention, diagnosis, scopic techniques are relatively inex-
therapy or rehabilitation. The tech- pensive, and automated procedures
nologies themselves may be classified such as cytological screening are be-
breaking genome as biologicals, pharmaceuticals, medi- coming more reliable.
cal devices and replacement and Lasers are being used in surgical
assistive devices. treatment, and microsurgery has be-
research will shift Biological medicine is the basis for come much more sophisticated. Ar-
the fundamental understanding of tificial joints and prostheses, using
the balance from disease processes. It has made possi- new materials and substitutes as well
ble the development of novel com- as improvements in traditional mate-
pounds, and has provided new meth- rials, have become valuable weapons
diagnosis and ods for the large-scale production of against disability. The quality of these
existing biologicals. It is the basis for and other devices such as cardiac
highly sensitive specific diagnostic pacemakers is continually improving.
treatment of disease tests and for the development of new Transplant surgery has a major future
vaccines. Recombinant DNA tech- with a rapidly ageing population. In-
niques are available for prenatal creasing efforts are also being made
to prediction or screening and postnatal examination, in the clinical application of the
to detect errors in the formation or xenotransplantation of cells, tissues
biological activity of peptides which and organs from animal donors to
early detection. could result in schizophrenia. They human recipients, and in the produc-
will also prove important in the de- tion of biologicals for human use from
velopment of new vaccines. transgenic and cloned animals.
As a result of the molecular and Some promising possibilities in
cell biology revolutions, screening the fields of biologicals and pharma-
procedures in medical and public ceuticals are new vaccines against in-
health diagnoses are being speeded fectious diseases, including combina-
up. A new generation of drugs is com- tion vaccines such as for DPT as well
ing into use which can exercise more as oral vaccine.
precise control over human body Key areas for general research in-
functions. Current ground-breaking clude sequencing genomes of major
genome research will shift the bal- pathogens and studying the spread of
ance from diagnosis and treatment of antimicrobial resistance. There will
disease to prediction or early detec- be an upsurge in the development of
tion, so that disease can be managed low-cost, simple diagnostic and thera-
prior to the onset of symptoms. Al- peutic devices for use in early detec-
208
Health agenda for the 21st century
tion of disease or relief from pain. As health development. Rapidly develop-
well as continuing developments in ing information technologies are chang-
biomaterials for prostheses, advances ing the way the world communicates,
in robotics are expected to have a con- with far-reaching consequences, includ-
siderable impact. ing in the area of public health.
In short, scientific and technologi- Information societies have three
cal developments in the broadest main characteristics. They use infor-
sense are contributing significantly to mation as an economic resource,
the provision of health care. Contin- stimulating business towards greater
ued investment in basic and applied efficiency (e.g. through the electronic
science will certainly pay off. Prop- transfer of money). Individual citizens
erly planned schemes for technology use information more intensively as
transfer should make it possible for consumers, to inform their choices,
developing countries to capitalize, for make their purchases and take greater
health, on advances in other coun- control over their lives.
tries, and there is great scope for re- The capacity of information tech- Properly planned
gional cooperation. nology has been increasing at an expo-
Technological advances may how- nential rate for nearly 20 years and
ever raise serious ethical issues which shows no sign of slowing down. These schemes for
require the urgent attention of the new information systems satellite
international community. The most broadcasting, telecommunications net-
recent example is the successful clon- works using fiberoptics and the
technology transfer
ing in 1997 of a sheep by somatic cell Internet are global.
nuclear transfer. Governments, re- Information technology can raise should make it
gional groupings and international education levels, strengthen commu-
bodies worldwide have reacted by nity links and stimulate public partici-
firmly opposing human reproductive pation in decision-making. In health, possible for developing
cloning. WHOs governing bodies it enables doctors to keep closer track
have stated categorically that the rep- of their patients progress through
lication of human individuals is ethi- sophisticated records management countries to
cally unacceptable. systems. Globally, it enables the sur-
veillance and monitoring of disease,
The information society and facilitates the rapid international capitalize, for health,
responses of organizations such as
Individuals are being expected to as- WHO to epidemics. The introduction
sume increasing responsibility for of information technology in health on advances in
their own health, within the support- care delivery and health systems man-
ive framework of the State. The avail- agement will enhance quality of care,
ability of meaningful information be- efficiency and cost-effectiveness in other countries.
comes central to their ability to make the management of individual and
choices. Each person creates health community health.
within the settings of everyday life (at There is concern that the shift to-
school, at work, at home). Societys wards information societies will widen
role is to create the conditions that the gap between developed and de-
allow the attainment of health by all veloping countries. International
its members. agencies, including WHO, have for
The information society provides several decades been facilitating the
the tools. Sharing the worlds store of information flow towards developing
global health knowledge through in- countries, with the expansion of in-
formation and communication tech- formation systems, libraries and
nology is a keystone to international archives, so that poorer nations can
209
The World Health Report 1998
obtain information at affordable cost The commitments and interests of
and build their own information in- international agencies, foreign aid,
frastructures. nongovernmental organizations and
community organizations shape the
Advances in politics of health and health care. The
communications business interests of pharmaceutical
and medical devices companies, as
Communication technology should be well as the motivations and ideologies
placed at the service of all, to facilitate of health care providers, also influ-
their access to the information they ence health and health care.
need. The new networks of informa- Workers health, for example, is
tion that are now developing could lay subject to trade and commerce poli-
the foundations of a new social struc- cies as well as to the process of in-
ture. No previous telecommunications dustrialization and the power of un-
advance, even the telephone and tel- ions. Satisfying the health demands
Since the attainment evision, has penetrated public con- of women, the aged, ethnic minori-
sciousness as quickly as the Internet. ties, children, the disabled and those
Its integration into conventional social with certain diseases such as AIDS in-
of health evokes and economic processes is taking place volves politics related to ideology, eth-
at an unprecedented speed, yet it may ics and the lack of political influence
be only the very beginning of the of these groups.
moral and emotional Internet explosion. Already, commu- The evaluation of the health-for-
nities and nations around the globe are all strategy carried out in 1997 illus-
responses, health starting to sketch out the cyberplaces trates that in many countries progress
of the 21st century. in traditional health indicators has
This technology should not only been insufficient to ensure the
policy cannot be contribute to promoting economic achievement of the goal. Even in
development and improving quality countries where the targets have been
of life it could remodel society. The reached, equity has not been
developed in a time and space devoted to health is- achieved, irrespective of political re-
sues in the media are expanding. In- gime or economic development level,
creasingly, media institutions are play- in spite of legislation to protect po-
moral vacuum. ing an active role in the social affairs litical and civil rights.
of the societies they serve. The me- The search for equity is at the
dia have a powerful role to play in heart of the political struggle. Gov-
partnership with the health sector, in ernments, regardless of their politi-
the service of health goals. cal style, should seek to meet health
needs through rearrangement of
Political trends health care systems. Recently in some
affecting health countries, the core public function of
ensuring equity has weakened as in-
Politics involve conflicts of power and dividual States reduce emphasis on
influence, and competition between social areas and transfer some respon-
interest groups. Through politics sibilities to the private sector and to
things can be done or prevented from local levels where mechanisms to
being done, and decisions are taken safeguard equity may be lacking or
about who gets what and when in so- weak.
ciety. Since the attainment of health Reforms have affected the content
evokes moral and emotional re- and formulation of social policies as the
sponses, health policy cannot be de- State modifies its role as designer, fin-
veloped in a moral vacuum. ancier, implementer and regulator of
210
Health agenda for the 21st century
policies. These modifications relate to If the global community does not
shifts in the final purpose of social poli- take action soon, hunger, malnutrition
cies, from universal access associated and resulting illnesses will persist,
with high cost and low impact for most natural resources will continue to be
to a new paradigm focused on the poor. degraded, and conflicts over scarce
This framework includes specific tar- resources such as water will become
geting strategies and equity with the even more common. For most of hu-
premise of treating unequally those manity, the world will not be a pleas-
who are socially and economically ant place to live. It does not have to
unequal. be this way. With foresight and deci-
As a result, communities have sive action, we can create a better
started to mobilize for their own fu- world for all people. We have the
ture through grassroots movements, knowledge and the skills and we still
nongovernmental organizations, and have the necessary resources, includ-
other means. Although community- ing natural resources.
based health care has become the new If the global community
rhetoric in many contexts, its effective- Health imperatives
ness is hampered by fragmentation,
lack of societal commitment and so-
for the 21st century does not take action
cial cohesion, and the value of illness On the unfinished agenda for
and health services as private goods.
There is a risk that the accelerat-
health, poverty remains the main soon, hunger,
item. The priority must be to reduce
ing global evolution, with the riches it in the poorest countries of the
it promises, will leave more than half world, and to eliminate the pockets malnutrition and
a billion people in poverty in the year of poverty that exist within countries,
2020. In spite of increasing globali- including among refugees. Policies di-
zation, national policies remain of rected at improving health and ensur- resulting illnesses will
paramount importance in determin- ing equity are the keys to economic
ing levels of employment and labour growth and poverty reduction.
standards, for example. While the Safeguarding the gains already persist, natural
current trend is towards international achieved in health depends largely on
responsibility for standard-setting in sharing health and medical knowl-
many key areas, and towards their edge, expertise and experience on a
resources will continue
implementation at the local level, na- global scale. Apart from establishing
tional governments have a role to play and expanding national health serv-
in policy setting and legislation, es- ices based on primary health care,
to be degraded, and
pecially in the social sector. This is industrialized countries can play a vi-
particularly so in cases where re-
sources have to be diverted from the
tal part in helping solve global health conflicts over scarce
problems. It is in their own interests
social sector because of globalization as well as those of developing coun-
of trade and services, which may re-
sult in a decline in the provision of
tries to do so. resources will become
Increased international coopera-
essential medical and health services. tion in health can be facilitated by a
While forecasters may not be ex- managed global network making use even more common.
pected to reach beyond the extrapo- of the latest communication technolo-
lation of known factors, leaders and gies. Global surveillance for the de-
policy-makers are mandated to do so. tection of and response to emerging
They must determine the global sce- infectious diseases is essential. As a
nario of the early 21st century and put result of increased global trade and
in place the building blocks that will travel, the prevention of foodborne
permit a quantum leap forward.
211
The World Health Report 1998
infections in particular is of increas- be better understood. Much more
ing importance. Wars, conflicts, refu- research is required in order to re-
gee movements and environmental duce disability among older age
degradation also facilitate the spread groups.
of infections as well as being health Concern for the older members
hazards in themselves. of todays society is part of the
Enhancing health potential in intergenerational relationships that
the future depends on preventing and need to be developed in the 21st cen-
reducing premature mortality, mor- tury. These relationships, vital for so-
bidity and disability. It involves ena- cial cohesion, should be based on eq-
bling people of all ages to achieve over uity, solidarity and social justice.
time their maximum potential, intel- The young and old must learn to
lectually and physically through edu- understand each others differing as-
cation, the development of life skills pirations and requirements. The
and healthy lifestyles. young have the skills and energies to
Concern for the older The health implications of enhance the life quality of their
healthy ageing the physical and elders. The old have the wisdom of
mental characteristics of old age and experience to pass on to the children
members of todays their associated problems need to of today and of coming generations.
intergenerational
to be developed in
212
Statistics
Annex 1
Members and Associate Members of WHO
As of 1 January 1998, WHO had 191 Members and two Associate Members. They are listed below
with the date on which they became a party to the Constitution or were admitted to associate
membership.
213
The World Health Report 1998 Statistics
T
he World Health Report 1998 OECD. The main source of estimates
Malawi* 9 April 1965 Somalia 26 January 1961
Malaysia* 24 April 1958 South Africa 7 August 1947 Life in the 21st century, a relating to demographic indicators,
Maldives* 5 November 1965 Spain* 28 May 1951 vision for all presents an over- including life expectancy at birth, fer-
Mali* 17 October 1960 Sri Lanka 7 July 1948 view of the global health situation and tility and infant mortality as well as
Malta* 1 February 1965 Sudan 14 May 1956 trends from the 1950s to 2025. Re- the number of deaths and population
Marshall Islands 5 June 1991 Suriname 25 March 1976 sults are based on an assessment car- by age, was the Population Division,
Mauritania 7 March 1961 Swaziland 16 April 1973
ried out in 1997 using 1997 or latest Department for Economic and Social
Mauritius* 9 December 1968 Sweden* 28 August 1947
Mexico 7 April 1948 Switzerland 26 March 1947 available data. The content of the re- Information and Policy Analysis,
Micronesia (Federated States of) Syrian Arab Republic port was determined essentially by its United Nations, hereinafter referred
14 August 1991 18 December 1946 theme as well as by the availability of to as United Nations Population Di-
Monaco 8 July 1948 Tajikistan 4 May 1992 information concerning key health vision (UNPD). A number of statisti-
Mongolia* 18 April 1962 Thailand* 26 September 1947 and health-related indicators. The cal values such as the under-5 mor-
Morocco* 14 May 1956 The Former Yugoslav Republic
majority of Member States still expe- tality rate were derived from those
Mozambique 11 September 1975 of Macedonia* 22 April 1993
Myanmar 1 July 1948 Togo* 13 May 1960 rience great difficulty in obtaining estimates, but otherwise no attempt
Namibia 23 April 1990 Tonga* 14 August 1975 valid and timely data on many indi- was made, for the present report, to
Nauru 9 May 1994 Trinidad and Tobago* 3 January 1963 cators such as disease morbidity and refine figures taken from recognized
Nepal* 2 September 1953 Tunisia* 14 May 1956 health-care coverage. international sources and research
Netherlands* 25 April 1947 Turkey 2 January 1948 Since 1979, the Member States of publications.
New Zealand* 10 December 1946 Turkmenistan 2 July 1992
WHO have carried out monitoring Surveillance data for a number of
Nicaragua* 24 April 1950 Tuvalu 7 May 1993
Niger* 5 October 1960 Uganda* 7 March 1963 and evaluation of the Global Strategy diseases (communicable and non-
Nigeria* 25 November 1960 Ukraine* 3 April 1948 for Health for All by the Year 2000 communicable) of major public
Niue 4 May 1994 United Arab Emirates 30 March 1972 three times. However, data coverage health concern are lacking. Global
Norway* 18 August 1947 United Kingdom of Great Britain and varies for the different indicators in and regional estimates of prevalence,
Oman 28 May 1971 Northern Ireland* 22 July 1946 the short list which is used for this incidence and even mortality are not
Pakistan* 23 June 1948 United Republic of Tanzania*
purpose. available for many of the diseases in-
Palau 9 March 1995 15 March 1962
Panama 20 February 1951 United States of America In general, official statistics re- cluding some of those targeted for
Papua New Guinea 29 April 1976 21 June 1948 ported to WHO are incomplete, and eradication, elimination or control.
Paraguay 4 January 1949 Uruguay* 22 April 1949 are often not comparable among Using whatever reliable estimates
Peru 11 November 1949 Uzbekistan 22 May 1992 countries, nor up to date. Therefore were available, diseases/conditions
Philippines* 9 July 1948 Vanuatu 7 March 1983 this report is also based on the best were assessed according to their ef-
Poland* 6 May 1948 Venezuela 7 July 1948
available and reasonably reliable data fect on peoples health at different
Portugal 13 February 1948 Viet Nam 17 May 1950
Qatar 11 May 1972 Yemen 20 November 1953 from all sources, which have been stages of life (i.e. infants and small
Republic of Korea* 17 August 1949 Yugoslavia* 19 November 1947 duly validated. Sources include na- children, older children and adoles-
Republic of Moldova 4 May 1992 Zambia* 2 February 1965 tional reports, reports of all WHO cents, adults and older people) in or-
Romania* 8 June 1948 Zimbabwe* 16 May 1980 Notes offices and information from WHO der to provide an overview of the situ-
Russian Federation* 24 March 1948 collaborating centres, as well as per- ation and trends.
... Data not available or not applicable.
Rwanda* 7 November 1962 Associate Members
Billion means a thousand million. sonal communications. Because many of WHOs activities
Saint Kitts and Nevis
3 December 1984 Puerto Rico 7 May 1992 Reference has also been made to in different fields are interdependent,
Tokelau 8 May 1991 $ denotes United States dollars.
* Member States that have acceded to the Convention Saint Lucia* 11 November 1980 publications and documents of other programmes have been clustered and
Saint Vincent and the Unless specified otherwise, data international bodies such as the their activities, products and other
on the Privileges and Immunities of the Specialized Agen-
cies and its Annex VII. Grenadines 2 September 1983 refer to 1997. United Nations, World Bank, FAO, outputs synthesized according to their
214 215
The World Health Report 1998 Statistics
target age groups. The aim is to pro- Least developed countries: Arab Emirates, Uruguay, Venezuela, A major constraint in the assess- were made to reduce the paucity of other indirect approaches should not,
vide a global overview of WHOs work Afghanistan, Angola, Bangladesh, Viet Nam, Yugoslavia, Zimbabwe. ment of the global health situation data by preparing guesstimates in however, give the mistaken impres-
during the year 1997, irrespective of Benin, Bhutan, Burkina Faso, Economies in transition: relates to data on health status. accordance with epidemiological and sion that the necessary data are al-
the organizational level at which ac- Burundi, Cambodia, Cape Verde, Albania, Armenia, Azerbaijan, Belarus, There are no clear positive measures statistical principles and procedures ready being collected by all develop-
tivities were carried out, i.e. country, Central African Republic, Chad, Bulgaria, Czech Republic, Estonia, of health. Even in respect of negative while ensuring a reasonable degree ing and developed countries; rather,
regional or interregional. Comoros, Democratic Republic of Georgia, Hungary, Kazakstan, ill-health measures, little information of reliability, and of international it is a matter of concern that use of
As of 1 January 1998 WHO had the Congo, Djibouti, Equatorial Kyrgyzstan, Latvia, Lithuania, Poland, is at present available on disability, comparability. Similarly in respect of such estimates may detract from the
191 Member States and two Associ- Guinea, Eritrea, Ethiopia, Gambia, Republic of Moldova, Romania, Rus- and the data on incidence and preva- incidence and prevalence some of the current efforts being made to com-
ate Members (see Annex 1). The glo- Guinea, Guinea-Bissau, Haiti, sian Federation, Slovakia, Tajikistan, lence of diseases, particularly in the estimates reflect comorbidity of dis- pile accurate and timely data on
bal health assessment relates only to Kiribati, Lao Peoples Democratic Turkmenistan, Ukraine, Uzbekistan. developing world, are notoriously eases and conditions. health indicators in the developing
Member States. For analytical pur- Republic, Lesotho, Liberia, Madagas- Developed market economies: unreliable and enormously variable. Global values for mortality, mor- world. Empirical data continue to be
poses they have been grouped ac- car, Malawi, Maldives, Mali, Mauri- Andorra, Australia, Austria, Belgium, Although mortality data are imper- bidity and disability from a large essential for assessing health situa-
cording to the United Nations classi- tania, Mozambique, Myanmar, Ne- Canada, Denmark, Finland, France, fect, they are nevertheless used to il- number of diseases and conditions tions, identifying problems and work-
fication and are described below. pal, Niger, Rwanda, Samoa, Sao Tome Germany, Greece, Iceland, Ireland, lustrate general patterns and orders were determined following extensive ing out solutions in the area of health
Least developed countries and Principe, Sierra Leone, Solomon Italy, Japan, Luxembourg, Monaco, of magnitude of major health prob- consultation on the quality and con- development. It would thus be appre-
(LDCs) are defined as Those low- Islands, Somalia, Sudan, Togo, Netherlands, New Zealand, Norway, lems. This report, based primarily on sistency of the estimates with experts ciated if readers would send their
income countries that are suffering Tuvalu, Uganda, United Republic of Portugal, San Marino, Spain, Sweden, four distinct measures of ill-health within the Organization and at WHO comments and suggestions for im-
from long-term handicaps to growth, Tanzania, Vanuatu, Yemen, Zambia. Switzerland, United Kingdom, mortality, incidence, prevalence and collaborating centres. Judicious use proving the quality of the estimates
in particular, low levels of human re- Developing countries exclud- United States of America. severe activity limitation (permanent was made of available data from a used in this report and assist WHO
sources development and/or struc- ing least developed countries: Throughout the report devel- and long-term) uses reasonably re- variety of sources and the most recent by suggesting more reliable data
tural weakness. To reflect the three- Algeria, Antigua and Barbuda, Argen- oped world refers to countries clas- liable data and estimates from a vari- data were reviewed, interpreted and sources for use in the future.
pronged approach that would cover tina, Bahamas, Bahrain, Barbados, sified as developed market economies ety of statistical sources. For exam- extrapolated in a global context. Cov- The World Health Report makes
more aspects of the development Belize, Bolivia, Bosnia and Herze- and economies in transition; and de- ple, the United Nations Population erage of diseases and conditions is re- prudent use of the limited number of
process, the Committee for Develop- govina, Botswana, Brazil, Brunei veloping world to LDCs and other Division biennially assesses the glo- stricted to those of major public pages available for producing a com-
ment Planning of the United Nations Darussalam, Cameroon, Chile, China, developing countries. In some cases bal demographic situation and makes health concern and falls far short of prehensive summary related to a spe-
has used the following criteria for an Colombia, Congo, Cook Islands, Costa the developed world has also been re- estimates of numbers of deaths by age the total spectrum of such diseases cific theme. We present information
initial selection: Rica, Cte dIvoire, Croatia, Cuba, ferred to as the industrialized coun- and sex for many countries. This re- covered by the ICD-10. The result- only once in the report in the form of
(i) GDP per capita; Cyprus, Democratic Peoples Repub- tries or developed countries in the port uses the 1996 assessment. While ing figures relating to 1997 indicate a table, graph or map, whichever is
(ii) augmented physical quality of life lic of Korea, Dominica, Dominican text. major differences may be considered orders of magnitude of health prob- most appropriate to convey the find-
index (APQL) consisting of life Republic, Ecuador, Egypt, El Salva- The designations used for group- indicative of actual disparities and lems associated with these selected ing, unless the finding is of such im-
expectancy at birth, per capita dor, Fiji, Gabon, Ghana, Grenada, ings of countries in the text and tables trends, caution is necessary in inter- diseases, but they lack the degree of portance and complexity as to warrant
calorie supply, combined primary Guatemala, Guyana, Honduras, India, are intended solely for statistical and preting small differences in values of precision necessary for any more in- presentation in more than one form.
and secondary school enrolment Indonesia, Iran (Islamic Republic of), analytical purposes and do not neces- different groups. depth disease-specific analysis. In
ratios and adult literacy; and Iraq, Israel, Jamaica, Jordan, Kenya, sarily express a judgement about the Country data on causes of spite of all these efforts, it is to be rec- Primary sources of data
(iii)economic diversification index Kuwait, Lebanon, Libyan Arab stage reached by a particular country death, in respect of communicable ognized that the uncertainties asso-
(EDI) consisting of the share of Jamahiriya, Malaysia, Malta, Marshall in the development process. and noncommunicable diseases and ciated with the statistical information Table A Basic indicators gives
manufacturing in GDP, share of Islands, Mauritius, Mexico, Micro- As countries are added to or re- conditions, pose a problem. Underre- and the epidemiological assumptions data on key health and health-related
employment in industry, per nesia (Federated States of), Mongo- moved from a particular group, re- porting, imprecise listing of causes add to the margin of error that would indicators relating to the world health
capita electricity consumption and lia, Morocco, Namibia, Nauru, Nica- vised estimates are computed for the and inaccurate diagnosis complicate in any event be involved in estima- situation. It contains data for 1997 or
the export concentration ratio. ragua, Nigeria, Niue, Oman, Pakistan, groups and subgroups of countries both national and international stud- tion procedures. for the latest available year in respect
The Committee then took into Palau, Panama, Papua New Guinea, retroactively to ensure their compa- ies of mortality. Furthermore, attrib- To carry out its directing and co- of WHOs 191 Member States. As far
consideration other special circum- Paraguay, Peru, Philippines, Qatar, Re- rability over time. Accordingly, data uting death to specific causes often ordinating functions at international as possible data are given for the early
stances such as trade and exchange public of Korea, Saint Kitts and Ne- by WHO region or by the United results in epidemiological and clini- and regional levels, WHO has since 1950s, late 1990s and for 2025 to re-
rate fluctuations and made a subjec- vis, Saint Lucia, Saint Vincent and the Nations classification in this report cal judgement in identifying under- 1990 been incrementally developing flect the global assessment of the past,
tive assessment and judgement when Grenadines, Saudi Arabia, Senegal, may differ from comparable figures lying causes. Following the rules and its database on global and regional es- present and future situation.
arriving at a final list. The list of 48 Seychelles, Singapore, Slovenia, South presented in earlier World Health procedures of the International sta- timates of mortality and morbidity by The following indicators which
LDCs approved by the United Na- Africa, Sri Lanka, Suriname, Reports (1995, 1996 and 1997) and tistical classification of diseases and diseases/conditions, based on official were used in the 1997 report have
tions General Assembly in 1994 is Swaziland, Syrian Arab Republic, in other WHO and UN publications, related health problems, tenth revi- country data supplemented by reli- been updated: life expectancy at
given below. Thailand, The Former Yugoslav Re- because of variations in base values, sion (ICD-10), unique causes were able national and international esti- birth; under-5 mortality rate; infant
public of Macedonia, Tonga, Trinidad country groupings and reference assigned to deaths and thereby dou- mates. The extensive use, in this re- mortality rate; age- and sex- standard-
and Tobago, Tunisia, Turkey, United years. ble counting was avoided. Efforts port, of data based on estimates and
216 217
The World Health Report 1998 Statistics
ized death rate; GNP per capita; case under Source. birth and exactly 5 years of age ex- years who have a weight that is below Source: WHO. 5. Economy
population (total and growth rate per All tables, figures and maps are pressed per 1000 live births. minus two standard deviations from 3.2 Antenatal care (% of live
annum); adult literacy; reported cases compiled especially for the World Source: Office of World Health Re- the median weight-for-age of the ref- births) refers to the percentage of 5.1 Gross national product
of leprosy, AIDS, tuberculosis, ma- Health Report 1998 on the basis of porting, using data given in the World erence population. women attended at least once during (GNP) per capita.
laria, measles and neonatal tetanus; data provided by WHO regional of- population prospects, 1996 revision Source: WHO. pregnancy by skilled health person- Source: World Bank. World develop-
immunization coverage (BCG, DPT3, fices and technical programmes, and the formula provided by the 2.10 Cancer. nel for reasons related to pregnancy ment report 1997. New York, Oxford
OPV3, measles and tetanus toxoid 2). IARC and UNPD, except for Fig. 7 United Nations Population Division. Sources: International Agency for (doctors and/or persons with mid- University Press, 1997.
New indicators added this year (source: REVES), Fig. 12 (source: 2.4 Age- and sex-standardized Research on Cancer (IARC), WHO. wifery skills who can diagnose and 5.2 Growth of Gross Domestic
are: ratio of female to male life expect- National Long Term Care Surveys, death rate is obtained by applying manage obstetrical complications as Product (GDP) and GDP per
2.11 Diabetes mellitus refers to the
ancy at birth; ratio of female to male United States), Fig. 19 (source: the age- and sex-specific death rates well as normal deliveries). Live births capita.
number of persons with diabetes in
under-5 mortality rate; deaths under UNESCO), and Table 7 (source: of a given population for a country or is used as a proxy for the total number Sources:
1997 and 2025.
age 50 (as a percentage of the total); United Nations Department of Eco- group of countries to a standard popu- of pregnancies. (a) United Nations. World economic
Source: WHO.
population: age 15-49 (females), ratio nomic and Social Affairs DESA). lation, the standard population being Source: WHO. and social survey 1997. New York,
of age 65+ to age <5 (both sexes), in 2.12 Acquired immune deficiency
the 1990 world population, estimated 3.3 Deliveries in health facilities United Nations, 1997.
syndrome (AIDS)/ human immu-
urban areas and in urban agglo- 1. Population and demography at 5.3 billion (sources 1a and 1b).
nodeficiency virus (HIV). (% of live births) refers to the per- (b) United Nations Department of
merations >1 million; total fertility rate Source: WHO. Economic and Social Affairs
Source: WHO. centage of deliveries in public and
(per woman); antenatal care and de- 1.1 Population size, growth rate, (DESA) personal communica-
2.5 Age-specific death rates refer private hospitals, clinics and health
liveries in health facilities. age and sex distribution, urbani- 2.13 Regular access to essential tion.
to the number of deaths in the age centres, irrespective of who attended
Data for most of the indicators zation. drugs refers to the percentage of the
groups 0-4, 5-19, 20-64 and 65+, per the delivery at these facilities. Live
were assembled by WHO from na- Sources: population with regular financial and
100 000 population in the same age births is used as a proxy for the total
tional reports on monitoring and evalu- (a) World population prospects 1950- geographical access to the most
groups (sources 1a and 1b). number of pregnancies.
ation of the Strategy and from various 2050 (with supplementary tabu- needed essential drugs (20-30),
Source: WHO. Source: WHO.
sources listed; data concerning health lations), 1996 revision. New York, whether generic or non-generic, in
status and health care were taken from United Nations, forthcoming. 2.6 Annual number of reported the public or private sector. 3.4 Water supply and sanitation
WHO publications or are estimates (b) Demographic indicators 1950- cases refers to the number of cases Source: WHO. coverage. Access to safe water re-
made by WHO programmes on the 2050, 1996 revision; Sex and age of selected diseases reported by fers to the percentage of the popula-
2.14 Micronutrient malnutrition.
basis of information supplied by Mem- annual 1950-2050, 1996 revision; Member States to WHO as of 31 tion with safe drinking-water available
Source: WHO.
ber States. Although every effort was Annual populations, 1950-2050, December 1997 for the year con- in the home or with reasonable ac-
cerned: leprosy, AIDS, tuberculosis, 2.15 Percentage of population un- cess to treated surface waters and
made to standardize the data for in- 1996 revision; Urban and rural derweight and overweight.
ternational comparison, care must be areas, 1950-2030, 1996 revision; malaria, measles, neonatal tetanus untreated but uncontaminated water
and poliomyelitis. In view of possible Source: WHO. such as that from protected
taken in using them for comparative Urban agglomerations, 1950-
analysis and in interpreting the results. delay in the reporting of these data 2.16 Neonatal and perinatal mor- boreholes, springs and sanitary wells.
2015, 1996 revision; and Age pat-
Table B Analytical tabulations to WHO, numbers given in this re- tality and maternal mortality. Access to adequate sanitation re-
terns of fertility, 1990-1995, 1996
are primarily based on the values port may differ from national values. Source: WHO. fers to the percentage of the popula-
revision. New York, United Na-
given in Table A. In addition, the fol- tions, 1996 (databases) . Source: WHO. tion with at least adequate excreta-
lowing health-related indicators ap- 2.7 Yellow fever, measles, neo- 3. Health care and disposal facilities which can effec-
tively prevent human, animal and in-
pear only in Table B: death rates for 2. Health status natal tetanus elimination status, environment sect contact with excreta.
the age group 20-64 (ratio female to hepatitis B, hepatitis C.
male). Figures refer to all 191 Mem- 2.1 Global health situation: mor- Source: WHO. 3.1 Immunization coverage for Source: WHO/UNICEF joint moni-
ber States, which in 1997 had an esti- tality, morbidity and disability, se- BCG, DPT3, OPV3 and measles toring programme. Water supply and
2.8 Life expectancy without se-
mated population of 5833 million, or lected diseases, all ages, 1997 es- refers respectively to the percentages sanitation sector monitoring report
vere disability.
99.7% of the world population. The timates. of infants surviving to age 1 who have 1996. Geneva, WHO, 1996.
Source: Rseau Esprance de Vie en
population data and other demo- Source: WHO. Sant (REVES). Contribution of the been fully immunized with BCG, a
graphic data are estimates of the 2.2 Number of deaths and age and international network on health ex- third dose of diphtheria-pertussis- 4. Education
UNPD following the 1996 population sex distribution, infant mortality pectancy and the disability process. tetanus vaccine, a third dose of oral
assessment. These figures serve as polio vaccine and measles vaccine. 4.1 Adult literacy rate.
rate and life expectancy at birth. Montpellier, 1997 (personal commu-
denominators for various rates and Sources: see section 1 Population nication). Immunization coverage for TT2 Source: UNESCO. World education
weights used for computing the ag- and demography, above. refers to the percentage of pregnant report 1998. Paris, UNESCO, 1998.
2.9 Underweight prevalence
gregate values in Table B. Further women immunized with two or more
2.3 Under-5 mortality rate refers among preschool children refers to
details are given in the reference pub- doses of tetanus toxoid given during
to the probability of dying between the percentage of children under 5
lications and documents listed in each pregnancy.
218 219
The World Health Report 1998 Statistics
Table A1. Basic indicators Life Under-5 Infant Age and sex Deaths GNP
Estimates are obtained or derived from relevant WHO programmes or from responsible international agencies expectancy mortality rate mortality standardized under per
for the areas of their concern at birth (years) rate death rate age 50 capita
Ratio Ratio (per 100 000 as %
Member Statesa Both female/ Both female/ population) of total
Life Under-5 Infant Age and sex Deaths GNP sexes male sexes male US$
expectancy mortality rate mortality standardized under per 1997 2025 1997 1997 2025 1997 1997 2025 1997 2025 1997 2025 1995
at birth (years) rate death rate age 50 capita
Ratio Ratio (per 100 000 as % Azerbaijan 71 76 1.12 39 25 0.85 34 22 701 520 31 15 480
Member Statesa Both female/ Both female/ population) of total Belarus 70 75 1.16 19 10 0.69 15 8 762 562 16 8 2 070
sexes male sexes male US$ Belgium 77 80 1.09 7 6 0.76 7 5 457 364 6 3 24 710
1997 2025 1997 1997 2025 1997 1997 2025 1997 2025 1997 2025 1995 Bosnia and Herzegovina 73 77 1.08 20 9 0.70 14 8 629 477 14 4 ...
Bulgaria 71 76 1.10 18 8 0.73 16 8 688 510 10 4 1 330
WHO Member States with values above all three health-for-all targets in 1997b Croatia 72 76 1.12 16 7 0.58 10 6 664 497 10 4 3 250
Czech Republic 73 77 1.09 9 6 0.41 9 6 656 489 7 3 3 870
Africa Denmark 76 78 1.07 8 6 0.71 7 5 517 417 7 3 29 890
Algeria 69 75 1.04 52 18 0.83 45 16 794 528 46 16 1 600 Estonia 69 75 1.17 18 8 0.64 12 6 782 543 14 6 2 860
Cape Verde 67 73 1.03 57 26 0.97 42 22 893 611 51 33 960 Finland 77 80 1.10 6 5 0.92 5 5 484 369 8 3 20 580
Mauritius 72 77 1.10 16 7 0.83 16 7 684 469 21 6 3 380 France 79 81 1.11 8 7 0.73 7 5 414 342 10 5 24 990
South Africa 65 74 1.10 68 23 0.81 48 20 926 582 47 21 3 160 Georgia 73 77 1.12 23 16 0.75 23 16 624 482 15 8 440
Germany 77 80 1.09 7 5 0.76 6 5 481 378 6 3 27 510
Americas Greece 78 81 1.07 10 7 0.99 8 6 428 353 6 3 8 210
Argentina 73 78 1.10 25 14 0.79 22 12 597 436 18 11 8 030 Hungary 69 74 1.14 16 8 0.75 14 8 796 579 13 6 4 120
Bahamas 74 79 1.09 17 9 0.63 14 6 586 419 31 11 11 940 Iceland 79 82 1.05 6 5 1.07 5 5 385 319 8 4 24 950
Barbados 76 80 1.07 12 7 0.68 9 6 493 377 9 5 6 560 Ireland 77 80 1.07 6 5 0.70 6 5 482 368 6 3 14 710
Belize 75 79 1.04 36 21 1.00 30 18 531 406 40 21 2 630 Israel 78 80 1.05 9 7 0.73 7 5 442 353 10 7 15 920
Brazil 67 74 1.12 45 23 0.76 43 21 834 569 40 20 3 640 Italy 78 82 1.08 8 6 0.88 7 5 420 329 6 3 19 020
Canada 79 81 1.08 7 7 0.90 6 5 401 334 9 4 19 380 Kazakstan 68 74 1.15 39 23 0.78 35 21 844 575 29 14 1 330
Chile 75 79 1.08 15 9 0.82 13 8 522 408 21 10 4 160 Kyrgyzstan 68 74 1.14 46 27 0.80 40 24 824 567 38 21 700
Colombia 71 76 1.08 30 20 0.75 23 17 680 482 40 19 1 910 Latvia 68 74 1.19 21 10 0.62 16 9 825 600 15 7 2 270
Costa Rica 77 80 1.06 14 8 0.78 12 8 460 372 25 10 2 610 Lithuania 70 75 1.17 16 9 0.74 13 6 722 550 17 8 1 900
Cuba 76 79 1.05 11 7 0.71 9 5 492 394 16 7 ... Luxembourg 76 80 1.09 7 5 0.77 6 5 489 378 7 3 41 210
Dominican Republic 71 77 1.06 43 20 0.79 34 15 673 462 44 18 1 460 Malta 77 80 1.06 10 6 0.50 8 5 464 365 7 3 ...
Ecuador 70 75 1.08 56 30 0.81 46 23 706 532 48 25 1 390 Netherlands 78 81 1.08 8 7 0.82 6 5 437 351 7 3 24 000
El Salvador 70 75 1.09 48 25 0.88 39 20 723 517 50 29 1 610 Norway 78 79 1.08 6 6 0.83 5 5 443 383 6 4 31 250
Guatemala 67 73 1.08 63 35 0.89 41 23 820 609 61 39 1 340 Poland 71 76 1.14 18 8 0.70 13 7 702 514 14 6 2 790
Honduras 70 75 1.07 47 24 0.80 35 18 706 513 59 35 600 Portugal 75 79 1.10 10 6 0.63 8 5 523 394 8 3 9 740
Jamaica 75 79 1.06 20 9 0.63 12 6 547 413 21 10 1 510 Republic of Moldova 68 73 1.13 27 17 0.71 27 17 852 599 20 11 920
Mexico 72 77 1.09 36 22 0.85 31 18 617 465 42 20 3 320 Romania 70 75 1.11 32 15 0.76 24 11 750 549 15 7 1 480
Nicaragua 68 75 1.07 57 30 0.83 45 23 778 533 62 36 380 Russian Federation 64 72 1.23 36 16 0.67 19 9 1 009 672 22 9 2 240
Panama 74 78 1.06 26 13 0.89 22 10 557 435 31 13 2 750 Slovakia 71 76 1.13 13 7 0.77 13 7 696 506 14 6 2 950
Paraguay 70 75 1.07 47 27 0.80 39 23 738 514 47 27 1 690 Slovenia 74 77 1.12 11 6 0.61 7 5 606 459 10 3 8 200
Peru 68 75 1.07 60 29 0.81 46 21 770 517 47 23 2 310 Spain 78 81 1.09 9 7 0.86 7 6 429 354 8 4 13 580
Suriname 72 77 1.07 25 10 0.71 24 9 672 470 27 11 880 Sweden 79 82 1.06 6 6 0.89 5 5 414 321 5 3 23 750
Trinidad and Tobago 74 78 1.07 15 7 0.58 14 6 578 416 18 7 3 770 Switzerland 79 81 1.09 7 6 0.83 5 5 413 342 8 4 40 630
United States of America 77 80 1.09 9 7 0.71 7 5 475 376 11 6 26 980 The Former Yugoslav
Uruguay 73 75 1.09 19 15 0.84 17 13 616 541 12 10 5 170 Republic of Macedonia 72 77 1.06 35 15 0.82 24 10 621 461 17 6 860
Venezuela 73 77 1.08 24 14 0.79 21 12 604 444 37 17 3 020 Turkey 69 75 1.08 58 22 0.79 45 16 754 514 38 15 2 780
Eastern Mediterranean Ukraine 69 75 1.16 21 10 0.69 18 9 805 563 15 7 1 630
United Kingdom 77 80 1.07 7 6 0.78 6 5 464 367 5 3 18 700
Bahrain 73 77 1.06 20 8 0.65 18 7 618 422 38 6 7 840 Uzbekistan 67 74 1.10 57 34 0.81 43 26 824 583 46 25 970
Cyprus 78 80 1.06 8 7 0.70 7 5 444 354 8 5 ...
Iran, Islamic Republic of 69 76 1.02 57 20 1.05 39 15 742 507 52 27 ... South-East Asia
Jordan 70 76 1.06 36 13 0.73 30 11 753 510 49 21 1 510 Democratic Peoples Republic of Korea 72 77 1.09 25 13 0.91 22 11 659 456 27 8 ...
Kuwait 76 79 1.06 15 7 0.67 15 6 490 371 34 8 17 390 Indonesia 65 73 1.06 59 20 0.81 49 18 949 597 43 15 980
Lebanon 70 75 1.05 33 15 0.78 29 13 737 535 30 13 2 660 Maldives 65 74 0.96 65 16 1.45 50 15 1 070 593 58 26 990
Oman 71 76 1.06 31 11 0.69 25 10 696 476 51 22 4 820 Sri Lanka 73 78 1.06 18 8 0.93 15 6 600 428 24 8 700
Qatar 72 77 1.08 23 8 0.67 17 7 1 075 444 41 4 11 600 Thailand 69 76 1.09 36 14 0.92 30 10 733 499 39 16 2 740
Saudi Arabia 71 77 1.05 28 8 0.77 24 7 675 428 44 12 7 040
Western Pacific
Syrian Arab Republic 69 75 1.07 39 14 0.71 33 13 787 530 48 21 1 120
Tunisia 70 76 1.03 46 16 0.88 38 13 754 508 36 12 1 820 Australia 78 81 1.08 8 6 0.82 6 5 420 343 9 5 18 720
United Arab Emirates 75 79 1.04 18 7 0.71 15 6 547 365 32 4 17 400 Brunei Darussalam 76 79 1.06 12 6 0.53 9 6 457 381 28 6 ...
China 70 75 1.05 40 17 1.24 38 16 737 537 24 8 620
Europe Fiji 73 77 1.06 23 8 0.65 20 8 618 444 29 8 2 440
Albania 71 75 1.09 49 25 0.93 32 17 675 543 32 13 670 Japan 80 82 1.08 6 6 0.83 4 4 370 318 6 3 39 640
Armenia 71 75 1.10 27 19 0.82 25 17 706 521 22 10 730 Malaysia 72 77 1.06 21 8 0.85 11 7 648 449 30 10 3 890
Austria 77 80 1.09 7 6 0.69 6 5 466 363 7 3 26 890 New Zealand 77 80 1.07 8 6 0.77 7 5 458 366 9 5 14 340
220 221
The World Health Report 1998 Statistics
Life Under-5 Infant Age and sex Deaths GNP Life Under-5 Infant Age and sex Deaths GNP
expectancy mortality rate mortality standardized under per expectancy mortality rate mortality standardized under per
at birth (years) rate death rate age 50 capita at birth (years) rate death rate age 50 capita
Ratio Ratio (per 100 000 as % Ratio Ratio (per 100 000 as %
Member Statesa Both female/ Both female/ population) of total Member Statesa Both female/ Both female/ population) of total
sexes male sexes male US$ sexes male sexes male US$
1997 2025 1997 1997 2025 1997 1997 2025 1997 2025 1997 2025 1995 1997 2025 1997 1997 2025 1997 1997 2025 1997 2025 1997 2025 1995
222 223
The World Health Report 1998 Statistics
224 225
The World Health Report 1998 Statistics
Philippines 17 867 70 724 3.0 2.3 1.5 0.3 0.9 56 72 15 94.6 3.6 2.1 South-East Asia
Republic of Korea 13 161 45 717 2.5 1.2 0.5 0.8 2.6 84 93 52 98.0 1.7 2.0 Bangladesh 30 099 122 013 2.6 2.2 1.4 0.3 0.7 20 37 10 38.1 3.1 2.1
Singapore 1 005 3 439 2.8 1.9 0.8 0.8 3.1 100 100 100 91.1 1.8 2.1 Bhutan 425 1 862 1.9 2.1 2.4 0.2 0.3 7 16 0 42.2 5.9 3.3
Solomon Islands 92 404 3.2 3.5 2.7 0.2 0.4 18 35 0 ... 5.0 2.7 Nepal 5 252 22 591 2.1 2.6 2.1 0.2 0.5 11 23 0 27.5 5.0 2.3
Vanuatu 42 178 3.1 2.6 2.3 0.2 0.5 19 33 0 ... 4.4 2.6
Viet Nam 20 087 76 548 2.0 2.2 1.3 0.4 0.9 20 30 6 93.7 3.0 2.1
Western Pacific
Cambodia 2 582 10 516 1.9 1.7 1.8 0.2 0.6 22 40 0 ... 4.5 2.3
WHO Member States with values below all three health-for-all targets in 1997 b Lao Peoples Democratic Republic 1 179 5 194 2.2 2.4 2.5 0.2 0.3 22 39 0 56.6 6.7 2.5
Papua New Guinea 1 079 4 500 2.3 2.3 1.9 0.2 0.5 17 30 0 72.2 4.7 2.3
Africa
Angola 2 513 11 569 1.6 2.9 2.9 0.1 0.2 33 51 19 ... 6.7 3.9 Other WHO Member States
Benin 1 294 5 720 1.9 2.9 2.8 0.2 0.3 40 59 0 37.0 5.8 3.3 Africa
Botswana 375 1 518 2.8 3.3 1.9 0.2 0.4 67 90 0 69.8 4.5 2.3
Burkina Faso 2 426 11 087 2.1 2.7 2.7 0.1 0.2 17 34 0 19.2 6.6 3.7 Sao Tome and Principe ... 138 1.3 2.5 1.6 ... ... 45 62 0 ... ... ...
Burundi 1 488 6 398 1.6 2.5 2.4 0.2 0.3 8 19 0 35.3 6.3 3.4 Seychelles ... 75 2.2 1.1 0.9 ... ... 56 71 0 ... ... ...
Cameroon 3 176 13 937 2.2 2.8 2.6 0.2 0.3 47 64 18 63.4 5.3 3.1 Swaziland 235 906 2.6 2.9 2.3 0.2 0.4 33 53 0 76.7 4.5 2.3
Central African Republic 818 3 416 1.9 2.3 2.0 0.2 0.4 40 56 0 60.0 5.0 3.0 Americas
Chad 1 541 6 702 1.8 2.3 2.3 0.2 0.3 23 37 0 48.1 5.5 3.4 Antigua and Barbuda ... 67 0.6 0.6 0.8 ... ... 36 50 0 ... ... ...
Comoros 144 651 2.5 3.4 2.7 0.1 0.3 32 49 0 57.3 5.5 2.8 Bolivia 1 886 7 774 2.3 2.2 1.9 0.3 0.6 63 77 17 83.1 4.4 2.4
Congo 625 2 745 2.5 3.0 2.7 0.2 0.2 60 74 39 74.9 5.9 3.6 Dominica ... 71 1.2 -0.1 0.5 ... ... 70 79 0 ... ... ...
Cte dIvoire 3 219 14 300 3.8 3.6 1.9 0.2 0.4 45 61 20 40.1 5.1 2.2 Grenada ... 93 0.4 0.0 0.7 ... ... 37 53 0 ... ... ...
Democratic Republic of the Congo 10 486 48 040 2.7 3.4 2.9 0.1 0.2 30 46 9 77.3 6.2 3.7 Guyana 245 847 2.1 0.6 1.0 0.4 1.2 37 54 0 98.1 2.3 2.1
Equatorial Guinea 96 420 -0.3 2.9 2.3 0.2 0.3 45 66 0 78.5 5.5 3.4 Saint Kitts and Nevis ... 41 -0.5 -0.5 0.5 ... ... 34 46 0 ... ... ...
Eritrea 786 3 409 2.6 2.1 2.4 0.2 0.4 18 32 0 ... 5.3 2.8 Saint Lucia ... 146 1.3 1.4 1.1 ... ... 37 50 0 ... ... ...
Ethiopia 12 972 60 148 2.3 2.8 3.0 0.1 0.2 17 32 4 35.5 7.0 4.0 Saint Vincent and the Grenadines ... 114 1.2 0.9 0.9 ... ... 51 72 0 ... ... ...
Gabon 258 1 138 1.1 3.0 2.3 0.4 0.4 53 71 0 63.2 5.4 3.1 Eastern Mediterranean
Gambia 284 1 169 2.8 3.6 2.0 0.2 0.4 31 49 0 38.6 5.2 3.1
Ghana 4 240 18 338 2.7 2.9 2.5 0.2 0.4 37 54 10 64.5 5.3 2.9 Egypt 15 890 64 465 2.3 2.4 1.5 0.4 1.0 45 59 23 51.4 3.4 2.1
Guinea 1 664 7 614 1.9 2.9 2.5 0.1 0.2 31 49 21 35.9 6.6 3.8 Iraq 4 966 21 177 3.2 3.0 2.5 0.2 0.5 76 84 30 58.0 5.3 2.8
Guinea-Bissau 255 1 112 0.9 2.7 2.0 0.3 0.3 23 38 0 54.9 5.4 3.4 Libyan Arab Jamahiriya 1 251 5 784 4.0 4.0 2.9 0.2 0.3 86 91 31 76.2 5.9 3.3
Kenya 6 665 28 414 3.3 3.5 2.1 0.2 0.4 31 51 7 78.1 4.9 2.1 Morocco 7 237 27 518 2.7 2.2 1.4 0.3 1.0 54 69 17 43.7 3.1 2.1
Lesotho 500 2 131 2.0 2.7 2.3 0.3 0.4 26 46 0 71.3 4.9 3.0 Pakistan 32 761 143 831 2.7 3.0 2.3 0.2 0.5 36 53 17 37.8 5.0 2.3
Liberia 571 2 467 2.9 1.4 3.8 0.2 0.3 46 62 0 38.3 6.3 3.7 Europe
Madagascar 3 566 15 845 2.5 3.3 2.8 0.1 0.3 28 46 0 ... 5.7 3.2 Andorra ... 74 7.4 5.1 2.7 ... ... 95 96 0 ... ... ...
Malawi 2 275 10 086 2.6 3.1 2.5 0.1 0.2 14 29 0 56.4 6.7 3.9 Monaco ... 32 1.1 1.2 1.0 ... ... 100 100 0 ... ... ...
Mali 2 571 11 480 2.3 2.8 2.8 0.1 0.2 28 47 0 31.0 6.6 3.9 San Marino ... 26 0.9 1.4 1.0 ... ... 95 98 0 ... ... ...
Mauritania 571 2 392 2.1 2.6 2.3 0.2 0.4 54 73 0 37.7 5.0 3.0 Tajikistan 1 454 6 046 3.3 2.7 1.7 0.3 0.7 33 47 0 ... 3.9 2.1
Mozambique 4 137 18 265 2.2 2.5 2.4 0.2 0.2 37 57 13 40.1 6.1 3.6 Turkmenistan 1 073 4 235 3.1 2.4 1.6 0.3 0.8 45 58 0 ... 3.6 2.1
Namibia 377 1 613 2.4 2.7 2.3 0.2 0.4 38 59 0 ... 4.9 3.0 Yugoslavia ... ... ... ... ... ... ... ... ... ... ... ... ...
Niger 2 137 9 788 2.9 3.3 3.0 0.1 0.2 19 36 0 13.6 7.1 4.0
South-East Asia
Nigeria 26 873 118 369 2.7 2.9 2.6 0.2 0.3 42 61 11 57.1 6.0 3.3
Rwanda 1 371 5 883 3.1 0.8 3.1 0.1 0.2 6 12 0 60.5 6.0 2.9 India 236 115 960 178 2.3 2.0 1.2 0.4 1.1 28 43 10 52.0 3.1 2.1
Senegal 2 019 8 762 2.7 2.8 2.4 0.2 0.3 45 62 21 33.1 5.6 3.2 Myanmar 12 213 46 765 2.2 2.0 1.4 0.4 0.8 27 43 9 83.1 3.3 2.1
Sierra Leone 1 032 4 428 1.7 1.8 2.3 0.2 0.2 35 53 0 31.4 6.1 3.6 Western Pacific
Togo 966 4 317 2.4 2.9 2.6 0.2 0.2 32 49 0 51.7 6.1 3.3 Cook Islands ... 20 0.9 0.0 0.9 ... ... 62 74 0 ... ... ...
Uganda 4 578 20 791 3.6 2.9 2.8 0.1 0.1 13 26 0 61.8 7.1 3.7 Kiribati ... 81 2.1 1.8 1.8 ... ... 37 51 0 ... ... ...
United Republic of Tanzania 7 273 31 507 2.9 3.2 2.5 0.1 0.3 26 45 6 67.8 5.5 3.2 Marshall Islands ... 59 3.5 3.1 3.0 ... ... 70 81 0 ... ... ...
Zambia 1 970 8 478 2.9 2.6 2.3 0.1 0.2 44 57 16 78.2 5.5 2.8 Micronesia, Federated States of ... 130 3.2 2.8 2.4 ... ... 29 46 0 ... ... ...
Zimbabwe 2 805 11 682 3.2 3.0 1.8 0.2 0.4 34 52 13 85.1 4.7 2.1 Mongolia 660 2 568 2.7 2.7 1.7 0.3 0.7 62 74 0 82.9 3.3 2.1
Americas Nauru ... 11 2.0 3.1 1.8 ... ... 100 100 0 ... ... ...
Haiti 1 826 7 395 1.7 1.9 1.9 0.3 0.3 33 51 21 45.0 4.6 3.5 Niue ... 2 -2.0 -3.4 -2.3 ... ... 29 40 0 ... ... ...
Palau ... 17 3.1 2.2 1.7 ... ... 72 81 0 ... ... ...
Eastern Mediterranean Samoa 39 168 2.3 0.4 1.5 0.4 0.9 21 33 0 ... 3.8 2.1
Afghanistan 5 247 22 132 2.3 1.2 2.8 0.2 0.3 21 37 10 31.5 6.9 3.6 Tonga ... 99 2.6 0.5 0.4 ... ... 44 63 0 ... ... ...
Djibouti 156 634 5.6 5.5 2.1 0.2 0.4 83 88 0 46.2 5.4 3.1 Tuvalu ... 10 0.9 2.6 0.9 ... ... 49 69 0 ... ... ...
Somalia 2 253 10 217 2.4 2.8 3.1 0.1 0.2 27 43 0 ... 7.0 4.0 a
Italics indicate less populous Member States (under 150 000 population in 1997).
Sudan 6 853 27 899 2.3 2.6 1.9 0.2 0.5 34 55 8 46.1 4.6 2.5 b
The three targets in WHOs strategy for health for all by the year 2000 relating to health status are: life expectancy at birth above 60 years; under-5 mortality rate below 70
Yemen 3 542 16 294 2.0 3.9 3.3 0.1 0.2 36 55 0 ... 7.6 4.2 per 1 000 live births; infant mortality rate below 50 per 1 000 live births.
... Data not available or not applicable.
226 227
The World Health Report 1998 Statistics
Table A3. Basic indicators Reported cases of selected diseases Immunization coverage (%) 1996 % of live births
Estimates are obtained or derived from relevant WHO programmes or from responsible international agencies during the specified year
for the areas of their concern Children immunized Pregnant Antenatal Deliveries
Member States a by age 12 months women care in health
facilities
Reported cases of selected diseases Immunization coverage (%) 1996 % of live births Neonatal
during the specified year Leprosy AIDS Tuberculosis Malaria Measles tetanus Tetanus
Children immunized Pregnant Antenatal Deliveries 1996 1996 1996 1995 1996 1996 BCG DPT3 0PV3 Measles toxoid 2 1996 1996
a
Member States by age 12 months women care in health
facilities Azerbaijan ... 2 2 480 2 844 151 2 90 95 97 99 ... 95 95
Neonatal Belarus ... 0 5 598 ... 395 0 ... 95 94 74 ... 100 100
Leprosy AIDS Tuberculosis Malaria Measles tetanus Tetanus Belgium ... 147 1 348 304 3 0 ... ... ... ... ... 90 99
1996 1996 1996 1995 1996 1996 BCG DPT3 0PV3 Measles toxoid 2 1996 1996 Bosnia and Herzegovina ... 3 2 220 ... ... ... ... ... ... ... ... ... ...
Bulgaria ... 10 3 109 ... 749 0 ... ... ... ... ... 100 100
WHO Member States with values above all three health-for-all targets in 1997 b Croatia ... 16 2 174 ... 123 1 90 91 91 91 ... ... ...
Czech Republic ... 18 1 969 ... 10 0 96 97 98 97 ... 99 99
Africa Denmark ... 155 484 ... 118 0 ... ... ... ... ... 100 99
Algeria ... 44 ... 18 21 003 16 94 77 77 75 36 58 76 Estonia ... 7 521 ... 34 0 99 90 93 86 ... 95 95
Cape Verde ... 36 ... 305 0 0 80 73 73 66 4 99 ... Finland ... 22 645 ... 0 ... 100 100 100 98 ... 100 99
Mauritius ... 5 ... ... 0 0 86 89 89 85 78 99 95 France ... 3 684 7 656 977 66 000 0 83 96 97 82 ... 99 99
South Africa 280 729 91 578 9 287 6 501 9 95 73 73 76 26 89 79 Georgia ... 3 3 522 ... 67 ... ... ... ... ... ... 95 95
Germany ... 1 169 11 814 ... 812 0 ... 45 80 75 ... 98 99
Americas Greece ... 208 ... ... 6 239 0 70 78 95 90 ... 95 99
Argentina 565 2 067 13 397 1 065 59 3 100 83 90 100 ... ... 90 Hungary ... 46 4 403 ... 26 0 100 100 100 100 ... ... ...
Bahamas ... 374 59 ... 0 0 ... 85 85 92 ... 100 99 Iceland ... 3 11 ... ... ... ... ... ... ... ... 100 99
Barbados ... 130 3 ... 0 0 ... 85 85 100 ... 98 98 Ireland ... 49 434 ... 53 0 ... ... ... ... ... 95 95
Belize ... 38 53 9 413 0 1 90 85 85 80 ... 96 76 Israel ... 39 369 ... 25 0 ... ... ... ... ... 90 99
Brazil 39 792 16 469 87 254 565 727 580 51 99 74 97 77 ... 74 81 Italy ... 4 891 4 155 ... 29 099 0 ... 50 98 50 ... 100 99
Canada ... 797 ... ... 327 ... ... ... ... ... ... 100 99 Kazakstan 1 2 13 944 ... 146 0 93 94 98 97 ... 92 95
Chile ... 323 4 038 ... 0 0 91 91 91 93 ... 91 98 Kyrgyzstan ... 0 4 093 ... 73 ... ... ... ... ... ... 90 95
Colombia 709 1 042 9 702 49 669 160 27 99 99 97 97 ... 83 77 Latvia ... 5 1 761 ... 3 0 100 64 77 82 ... 95 95
Costa Rica 15 192 162 ... 24 ... 91 84 84 86 ... 95 98 Lithuania ... 2 2 608 ... 36 0 98 91 93 96 ... 95 95
Cuba 262 94 1 579 20 0 ... 99 97 95 98 ... 100 99 Luxembourg ... 12 41 ... 25 ... ... ... ... ... ... 98 99
Dominican Republic 229 367 6 006 1 808 0 0 72 85 84 81 ... 97 92 Malta ... 4 28 ... 16 0 96 84 92 51 ... 99 98
Ecuador 115 67 6 327 18 128 42 34 100 88 89 79 ... 75 64 Netherlands ... 377 1 678 312 57 0 ... 97 97 94 ... 95 69
El Salvador ... 417 1 686 3 362 1 5 100 98 96 96 ... 69 51 Norway ... 50 217 ... 10 ... ... ... ... ... ... 99 99
Guatemala ... 831 3 496 24 178 1 12 77 73 73 70 ... 53 23 Poland ... 96 15 358 ... 669 ... ... ... 95 ... ... 99 99
Honduras ... 797 4 176 59 446 4 4 98 95 95 91 ... 73 45 Portugal 1 720 5 248 ... 111 2 91 95 ... 99 ... 95 94
Jamaica ... 527 121 10 4 0 98 92 92 96 ... 98 79 Republic of Moldova ... 1 2 922 ... 344 0 98 97 99 98 ... 90 95
Mexico 523 4 216 10 852 7 316 180 60 99 100 95 93 ... 71 63 Romania ... 554 24 189 ... 940 0 100 98 ... 94 ... 94 99
Nicaragua ... 25 3 003 69 444 0 1 100 91 99 90 ... 71 59 Russian Federation ... 46 111 075 ... 8 184 0 97 87 97 95 ... 95 95
Panama ... 243 1 099 730 0 0 100 92 92 90 ... 72 84 Slovakia ... 0 1 503 ... 0 0 ... 98 98 99 ... 95 95
Paraguay 401 50 2 148 898 13 8 89 80 81 81 ... 83 55 Slovenia ... 8 563 ... 8 0 ... ... ... ... ... 98 100
Peru 90 998 41 739 192 629 105 45 100 100 100 87 ... 64 46 Spain 12 5 678 8 331 ... 4 457 ... ... ... ... ... ... 96 96
Suriname 64 2 53 6 606 0 1 ... 80 79 78 ... 100 ... Sweden ... 133 497 ... ... ... ... ... ... ... ... 100 99
Trinidad and Tobago ... 412 205 35 0 0 ... 89 90 88 ... 98 96 Switzerland ... 322 764 ... 1 0 ... ... ... ... ... 99 99
United States of America 157 36 693 21 337 700 489 ... ... ... ... ... ... 94 99 The Former Yugoslav
Uruguay ... 156 701 ... 2 0 100 86 86 84 ... 80 96 Republic of Macedonia ... 2 724 ... 846 ... ... ... ... ... ... 90 91
Venezuela 534 634 5 576 16 371 89 12 89 57 73 64 ... 74 97 Turkey ... 37 20 212 82 096 27 171 61 69 84 83 84 ... 62 60
Ukraine ... 146 23 414 ... 8 607 ... ... ... ... ... ... 100 95
Eastern Mediterranean
United Kingdom ... 1 214 6 238 ... 2 569 0 ... 94 96 92 ... 99 99
Bahrain ... 5 156 192 74 0 ... 98 98 95 54 96 97 Uzbekistan ... 1 11 919 ... 893 0 ... ... ... ... ... 90 90
Cyprus ... 4 24 1 55 0 ... 98 98 90 ... 100 98
South-East Asia
Iran, Islamic Republic of 54 35 14 189 67 532 2 329 21 90 96 97 95 50 62 65
Jordan ... 4 474 197 448 2 ... 100 100 98 41 80 78 Democratic Peoples Republic of Korea ... 0 ... ... 0 2 99 99 99 99 ... 100 100
Kuwait ... 5 400 654 14 1 ... 100 100 99 21 99 97 Indonesia 15 071 32 24 647 1 460 569 15 339 814 100 93 90 93 ... 82 18
Lebanon ... 6 836 27 2 4 ... 94 94 85 ... 85 ... Maldives ... 2 212 17 0 0 98 95 95 94 ... 95 ...
Oman ... 12 222 1 801 24 0 96 100 100 98 51 98 82 Sri Lanka 1 528 11 5 439 142 294 158 7 88 92 90 86 81 100 94
Qatar ... 2 257 475 38 0 98 92 92 86 ... 100 87 Thailand 1 197 17 942 39 871 82 743 5 677 32 98 96 96 ... 88 77 ...
Saudi Arabia 112 100 ... 18 751 2 407 28 91 93 93 92 60 87 86 Western Pacific
Syrian Arab Republic ... 9 5 200 626 2 060 61 100 96 96 95 78 33 37 Australia ... 573 ... 623 ... ... ... ... ... ... ... 100 99
Tunisia ... 55 2 387 49 533 2 87 91 91 86 48 71 86 Brunei Darussalam ... 2 ... 46 ... ... ... ... ... ... ... 100 98
United Arab Emirates ... 0 507 2 914 425 0 98 90 90 90 ... 95 95 China 1 845 38 469 358 ... 68 404 2 543 97 95 96 97 13 79 51
Europe Fiji ... 0 200 ... 39 0 100 97 99 94 82 100 95
Albania ... 1 738 ... 1 203 0 94 98 100 92 ... ... 95 Japan ... 294 42 122 ... ... ... ... ... ... ... ... 99 99
Armenia ... 6 928 ... 2 061 0 82 85 97 89 ... 95 95 Malaysia 293 300 12 902 59 208 ... ... ... ... ... ... ... 90 90
Austria ... 130 1 375 ... 0 ... ... ... ... ... ... 100 99 New Zealand ... 56 323 ... ... ... ... ... ... ... ... 95 95
228 229
The World Health Report 1998 Statistics
Reported cases of selected diseases Immunization coverage (%) 1996 % of live births Reported cases of selected diseases Immunization coverage (%) 1996 % of live births
during the specified year during the specified year
Children immunized Pregnant Antenatal Deliveries Children immunized Pregnant Antenatal Deliveries
Member States a by age 12 months women care in health Member States a by age 12 months women care in health
facilities facilities
Neonatal Neonatal
Leprosy AIDS Tuberculosis Malaria Measles tetanus Tetanus Leprosy AIDS Tuberculosis Malaria Measles tetanus Tetanus
1996 1996 1996 1995 1996 1996 BCG DPT3 0PV3 Measles toxoid 2 1996 1996 1996 1996 1996 1995 1996 1996 BCG DPT3 0PV3 Measles toxoid 2 1996 1996
Philippines 4 051 51 276 295 366 844 ... ... ... ... ... ... 43 83 28 South-East Asia
Republic of Korea 39 22 31 134 131 71 0 ... ... ... ... ... 96 99
Bangladesh 11 225 0 63 471 152 729 4 929 759 100 97 98 96 90 23 5
Singapore ... 92 737 316 ... ... ... ... ... ... ... 100 99
Bhutan 37 0 1 271 23 195 9 0 98 87 86 85 15 51 11
Solomon Islands ... 0 289 118 521 0 1 96 97 98 90 ... 71 80 Nepal 6 602 37 22 970 9 718 8 513 171 92 75 77 80 18 15 6
Vanuatu ... 0 126 8 318 4 2 72 67 68 61 15 90 65
Viet Nam 2 883 375 74 711 666 153 5 156 257 95 94 94 96 96 78 70 Western Pacific
WHO Member States with values below all three health-for-all targets in 1997 b Cambodia 2 404 300 14 857 ... 2 814 9 90 75 76 72 36 52 7
Lao Peoples Democratic Republic 298 16 1 440 311 593 917 17 61 58 68 73 31 25 7
Africa Papua New Guinea 231 69 5 087 926 206 ... ... 78 55 57 44 50 70 ...
Angola 157 115 15 424 156 603 251 116 74 42 42 65 28 25 16 Other WHO Member States
Benin 592 503 2 372 579 300 1 365 16 90 80 80 74 75 60 20
Botswana ... 1 511 6 636 17 599 1 096 0 67 83 81 82 61 92 66 Africa
Burkina Faso 668 972 1 814 501 020 18 534 15 61 48 48 54 27 59 43 Sao Tome and Principe ... 6 ... ... 0 0 85 68 68 57 49 ... ...
Burundi ... 576 3 796 932 794 16 099 21 77 63 63 50 33 88 20 Seychelles ... 2 15 ... 2 0 100 100 100 98 100 ... ...
Cameroon 707 1 485 3 049 221 017 7 108 126 54 46 46 46 12 73 62 Swaziland ... 249 3 893 ... 2 199 1 68 70 71 59 65 70 56
Central African Republic 468 2 077 ... 127 248 17 94 53 53 46 15 67 50 Americas
Chad 982 1 242 1 936 ... 9 223 219 41 20 20 31 19 30 15 Antigua and Barbuda ... 13 5 ... 0 1 ... 100 100 100 ... ... ...
Comoros ... 0 140 187 082 0 1 55 60 60 43 25 69 20 Bolivia 32 28 10 194 46 911 7 14 98 82 82 98 ... 52 42
Congo 317 0 ... ... 3 897 7 58 50 50 39 16 55 ... Dominica ... 14 10 ... 0 0 100 100 100 100 ... ... ...
Cte dIvoire 1 734 6 000 13 104 4 515 20 858 351 68 55 55 65 22 83 45 Grenada ... 18 ... 1 0 0 ... 80 80 85 ... ... ...
Democratic Republic of the Congo 5 526 0 45 999 ... 9 546 194 51 36 36 41 20 66 ... Guyana ... 144 314 59 311 0 0 88 83 83 91 ... 95 90
Equatorial Guinea ... 74 ... 12 530 1 2 99 64 64 61 63 37 5 Saint Kitts and Nevis ... 6 3 ... 0 0 ... 100 98 100 ... ... ...
Eritrea 8 896 5 220 ... 1 783 2 52 46 46 38 23 19 5 Saint Lucia ... 14 ... ... 0 0 89 88 88 95 ... ... ...
Ethiopia 4 747 832 171 033 ... 1 586 5 87 67 67 54 36 20 10 Saint Vincent and the Grenadines ... 19 ... ... 0 0 100 100 100 100 ... ... ...
Gabon 26 318 891 ... 70 0 54 41 41 38 4 86 79
Eastern Mediterranean
Gambia ... 78 1 242 ... 15 1 99 97 97 89 92 91 ...
Ghana 1 451 1 166 10 449 1 175 000 34 273 108 65 51 52 53 14 86 42 Egypt 1 332 14 12 338 322 4 403 643 98 91 91 92 57 53 27
Guinea 3 326 922 4 286 512 814 9 334 289 59 48 48 49 43 59 25 Iraq ... 15 29 196 89 984 256 74 99 94 95 97 65 59 49
Guinea-Bissau 67 37 1 728 ... 73 8 68 53 54 49 20 50 ... Libyan Arab Jamahiriya 14 0 1 282 30 ... 0 99 96 96 92 ... 100 ...
Kenya 234 6 520 34 980 4 343 190 3 572 23 52 46 43 38 21 95 44 Morocco 79 66 31 771 197 1 324 14 96 95 95 93 46 45 37
Lesotho ... 352 4 361 ... ... ... 55 58 58 82 10 91 50 Pakistan 1 405 19 4 307 111 836 1 090 2 012 93 77 77 78 54 27 13
Liberia 1 003 18 840 ... 1 570 74 84 45 45 44 35 83 ... Europe
Madagascar 3 921 5 12 718 ... 5 961 61 87 73 73 68 17 78 45 Andorra ... ... 17 ... ... ... ... ... ... ... ... ... ...
Malawi 509 4 158 20 630 ... 9 120 1 95 90 82 89 56 90 55 Monaco ... 1 0 ... ... ... ... ... ... ... ... ... ...
Mali 1 581 594 3 655 ... 10 846 37 76 52 52 55 19 25 24 San Marino ... 3 0 ... ... ... ... ... ... ... ... ... ...
Mauritania 36 14 ... ... ... ... 93 50 50 53 28 49 40 Tajikistan ... 0 1 647 6 144 21 ... ... ... ... ... ... 90 92
Mozambique 4 225 2 086 18 443 ... 9 251 37 83 60 60 67 ... 54 27 Turkmenistan ... 0 2 072 ... 96 ... ... ... ... ... ... 90 90
Namibia ... 2 615 6 773 105 593 4 901 20 79 70 71 61 75 88 67 Yugoslavia ... ... ... ... ... ... ... ... ... ... ... ... ...
Niger 1 219 652 ... 822 305 64 723 40 50 23 23 43 36 30 16 South-East Asia
Nigeria 6 871 308 24 063 ... 88 675 1 117 43 24 26 38 34 60 31
India 415 302 901 1 300 935 2 800 000 47 072 1 313 96 88 90 81 75 62 26
Rwanda ... 0 3 535 ... 3 988 1 93 95 99 36 43 94 25
Myanmar 6 935 690 22 201 642 751 1 684 61 92 88 87 86 63 80 ...
Senegal 427 141 8 516 ... 2 243 22 90 80 80 80 39 74 47
Sierra Leone 571 43 3 241 ... ... ... 77 65 65 79 70 30 20 Western Pacific
Togo 327 1 527 1 654 ... ... ... 63 82 82 39 43 43 8 Cook Islands ... 0 0 28 008 0 0 90 75 75 72 62 ... ...
Uganda 886 3 021 27 356 ... 26 198 167 100 79 79 79 77 87 30 Kiribati ... 0 327 ... 13 0 100 79 82 64 41 ... ...
United Republic of Tanzania 2 747 0 44 416 2 438 040 5 049 19 90 82 82 78 31 92 53 Marshall Islands ... 0 56 ... 0 0 98 78 77 69 59 ... ...
Zambia 511 4 552 40 417 2 742 118 9 459 15 100 83 83 93 85 92 51 Micronesia, Federated States of 288 0 94 ... ... ... ... ... ... ... ... ... ...
Zimbabwe 54 9 129 35 735 330 002 35 328 5 79 76 76 77 65 93 69 Mongolia ... 0 2 987 ... 128 0 92 90 90 88 ... 90 97
Americas Nauru ... 0 ... ... ... ... ... ... ... ... ... ... ...
Niue ... ... 2 ... 0 0 100 100 100 100 ... ... ...
Haiti 72 0 6 632 23 140 1 ... ... ... ... ... ... 68 20 Palau ... 0 5 ... 0 0 0 98 100 99 ... ... ...
Eastern Mediterranean Samoa ... 2 37 ... 87 0 98 95 95 96 98 52 ...
Afghanistan 27 0 ... ... ... ... ... ... ... 42 ... 8 5 Tonga ... 1 22 ... 0 0 100 99 99 95 95 ... ...
Djibouti ... 358 3 071 3 359 410 0 58 49 49 47 47 76 75 Tuvalu ... 0 ... ... 51 0 88 87 85 94 ... ... ...
a
Somalia 38 0 3 251 ... 1 830 102 ... ... ... ... ... 40 2 Italics indicate less populous Member States (under 150 000 population in 1997).
b
Sudan 2 126 221 20 280 232 177 2 559 40 96 79 80 75 44 54 18 The three targets in WHOs strategy for health for all by the year 2000 relating to health status are: life expectancy at birth above 60 years; under-5 mortality rate below 70 per
Yemen 456 60 14 364 ... ... ... 50 54 54 46 19 26 12 1 000 live births; infant mortality rate below 50 per 1 000 live births.
... Data not available or not applicable.
230 231
The World Health Report 1998
232