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WHO World Health Organization |
Urgent Messages to the World Health Leaders and to You!
The 53rd World Health Assembly met in Geneva, Switzerland, on May 15-20, 2000. This is the "Parliament" of WHO bringing together the ministers of health and other national and international health leaders from the 193 Member States of the Organization. They debate and discuss all pertinent and important issues related to health and disease in the world, and set an agenda for the coming year and beyond. Therefore, although we do not always think about it, the World Health Assembly has direct influence on all of our lives.
The Director-General of WHO, Dr. Gro Harlem Brundtland, provided as usual an overview in the form of an annual World Health Report, and addressed the participants and the whole world with her messages and concerns.
As a positive note for us all, Dr.
Brundtland said that the year 2005 will be the date when poliomyelitis shall be eradicated
from this earth. It will be a tremendous victory for mankind, as was the eradication of
smallpox that took place only some 25 years ago. The elimination of leprosy is likely to
be achieved already by the end of this year! This means that the 2.8 million remaining
sufferers of this terrible and mutilating disease will have the treatment and be cured.
But the successes and good news must not make us forget the new threats and plagues of our societies. For instance, there is immense suffering caused by HIV/AIDS. Especially Africa is in a difficult situation, but the warning signals come very timely to Eastern Europe and Russia as well. There is no time to be wasted if we want to prevent the catastrophe from taking place. WHO has started to negotiate with several pharmaceutical companies to take a fresh look at how to increase access to relevant drugs against HIV/AIDS. Still the best cure is prevention, but nevertheless we cannot accept the fact that only people in rich countries would have access to effective drugs that can slow down the disease.
Dr. Brundtland drew the attention to complex humanitarian emergencies like the ones in the North Caucasus and many other trouble spots in the world. Numerous lives can be saved when health issues are addressed early on. If we are really to offer hope, we go further than relief. We focus on relief and social reconstruction at the same time. Indeed, health often serves as a bridge for peace and reconciliation. This is what WHO is aiming at in the North Caucasus today.
"What makes a good health system? What makes a health system fair? How do we know if a health system is performing as well as it could?" Dr. Brundtland asked the ministers of health. We have to indicate clearly that a large proportion of the world’s population cannot access the basic health services they need. WHO has started to critically assess the performance of our health care systems. Those, whose systems are not performing well, may question the results. However, we must be bold and outspoken, and address especially issues of access and quality of services to the poor. Again, a very timely remark to be taken into account in our work in Russia.
Towards the end of her speech the Director-General said: "Let’s talk about tobacco. Agreeing on a ban on advertising is a key. Because it is absolutely right. It has been proven again and again that it makes a difference. Our work will not be done until tobacco-related deaths are drastically reduced. So do it! Time is not on our side. Do not allow any extra millions to be added to the death row of tobacco"1 .
Dr. Mikko Vienonen
Special Representative of the WHO Director-General in Russia
1 Note: The anti-smoking legislation presently being debated in the Russian Duma does not include prohibition of tobacco advertising.
Parliamentary Hearings on the Demographic Crisis in Russia
On May 30, the State Duma organized a parliamentary hearing to discuss the problem of the country’s diminishing population. Since 1992 the number of people living in Russia has dropped by 5.8 million hearings. In the beginning of the year 2000 the official census was 145.5 million inhabitants.
The reasons for the unfortunate situation are simple:
– Too few babies are being born;
– Mortality has risen from what it has been earlier.
Will the Russian nation eventually disappear? Who will keep the economy, production, services, defence, etc. going if new children are not born to replace those who die? In the beginning of the 1990s the number of deaths became higher than the number of births. Since 1985 the birth rate went down from 15 births per 1,000 people to approximately 8. During the same time mortality rose from 11 deaths per 1,000 people to approximately 15. Presently a woman has on average only 1.17 children.
The parliamentarians had a lively debate on the situation and what should be done about it. The simple solution attracted some: ban contraceptives, abortion and family planning information, and force the women to give birth to more babies. Serious experts and WHO warned against such experiments. The experiences from some countries that have implemented such measures have been totally counterproductive and disastrous.
Some speakers suggested positive incentives for families who will have more than one child. Although support to families with children has a beneficial effect on the well being of children, from the demographic point of view it has not proven very successful.
Clearly, the most important reason for the Russian demographic crisis is excessive mortality – and even more precisely – excessive AVOIDABLE mortality.
The equation is actually quite simple. The Russian man dies prematurely at the average age of 59.8 years – some 14 years younger than his West European brother. Women fare a bit better and can expect to live 72.2 years – "only" some 5-6 years less than their sisters in the west. What do die of?
· Over 700 people die every day much earlier than they should of cardiovascular diseases and cancer because of tobacco smoking.
· About 700 people die every day prematurely of liver cirrhosis, alcohol poisoning, accidents and suicide because of alcohol abuse.
· Accidents and violent deaths are the third biggest killer of Russian men.
A simple calculation shows that during the last 10 years some 7 million Russians have lost their lives prematurely because of these three largely avoidable causes.
There are many other important causes such as tuberculosis, drug abuse, inappropriate nutrition, poorly functioning health care services, etc., but they still come far behind the previously mentioned three big killers. From the demographic point of view the "three biggest killers" are the ones that you should not omit, if you truly want to make a difference.
HIV/AIDS should probably be added to this list. Russia is right now on the verge of a serious epidemic, and judging from the number of sexually transmitted diseases, the results can be devastating.
WHO’s solution to the demographic crisis is a comprehensive health policy and broad intersectoral action. The framework is already there: we call it Health for All in the 21st Century. When it comes to real improvements in the health of the masses and demography, only changes in people’s behaviour can help.
But as long as a bottle of vodka costs as much as a kilogram of apples, milk is more expensive than beer and a pack of cigarettes cheaper than chewing gum, one ought to worry about the demographic crisis. Under such circumstances any country would have a demographic crisis. The Parliamentarians and the Government have the keys to the problems in your hands. Please, use them!
Dr. Mikko Vienonen
Special Representative
of the WHO Director-General
in Russia
Figure: Real growth, Mortality and Birth rate in Russia 1940–1997
"...From the Diary of a WHO TB Doctor in Russia…"
Five years ago WHO launched its first pilot tuberculosis (TB) control project in the former Soviet Union. Despite quite sufficient experience in the Ivanovo Oblast, the "DOTS" strategy still has to fight against many traditional Russian TB control methods. "DOTS" stands for "direct observed treatment, shortcourse": a cost-effective approach to combat TB, based on a standard 4-drug regimen, administered during 6–9 months under direct observation of a health care worker. Priority is given to infectious patients, diagnosed by (inexpensive) sputum smear microscopy, and most of the treatment is performed on an ambulatory basis at paramedic points of the general health care system.
The traditional Russian TB control strategy, however, favours expensive mass screening with miniature radiography and individualised treatment schemes during lengthy hospitalisations. Frankly speaking, both the WHO and the traditional Russian approaches have a similar treatment outcome, but the price of the Russian approach is excessively higher and more inconvenient to the patients!
To overcome these contradictions, WHO together with our collaborating center on TB control, the Central TB Research Institute (CTRI) of the Russian Academy of Medical Science decided to run a refresher course in DOTS.
Tuesday 25/4/2000. Ivanovo TB Dispensary.
… All the participants seem to be very enthusiastic. Apparently, due to economic constraints, it is long since that many of them have met last time. Today we tackle the hot issue of standardised treatment regimens versus individualised ones. As expected, the discussion becomes tough. Hearing the participants actively debating with the expert from CTRI, Professor Punga, I realise how lucky I am to be amidst so many talented medical people. A trainer can learn a lot from his students…
Wednesday 26/4/2000. Ivanovo TB Dispensary.
... Every morning we leave enough time for the participants to briefly present their specific situations, tell about obstacles, and give recommendations on how to improve the project. Today the TB specialist of the referral psychiatric TB hospital of the Oblast has the word. Her speech is impressive but full of poignant sorrow.
Her hospital houses about 180 patients under very harsh conditions. Last winter, it was 4°C because of the broken heating system. Mattresses, blankets, sheets, food, drugs are in short supply. The walls of the building are crumbling. I know that she is not exaggerating because I have visited this hospital myself. I have seen a lot of hospitals with difficult conditions all over the former Soviet Union, but this one defies all descriptions. How dedicated should the medical staff be to carry on in such a situation! I stand up and shake her hand, thanking her for her work. "What can we do, Dr. Hans ! ", she responds, "we must carry on and continue the work …"
Friday 28/4/2000. Ivanovo TB Dispensary
…The course is over. I see satisfied faces. The Chief of the Oblast Health Administration opens the small celebration and confirms that the Governor signed a decree to increase the existing daily food ration for TB patients. Good news! USAID, our donor, will be satisfied that the money is well spent. While we drink Na pososhok (the last drink), we enthusiastically decide to get together each quarter. Za zdorovje!
Dr. Hans Kluge
WHO TB Project Manager