The Work of WHO in the Eastern Mediterranean Region
Annual Report of the Regional Director
1 January - 31 December 1999

Promotion and protection of health

4.1 Reproductive, family and community health and population issues

4.2 Healthy behaviour and mental health

4.3 Nutrition, food security and safety

4.4 Environmental health

4.1 Reproductive, family and community health and population issues

Promotion of reproductive health and family planning

Safe motherhood activities remained a priority issue in the Region in 1999. Strong emphasis was maintained on activities for the reduction of maternal and perinatal mortality and morbidity. Pursuant to the 1998 Sana'a Declaration, the Regional Office promoted the value of accurate and appropriate data on maternal and neonatal deather and diseases through surveillance; intercountry and national workshops were held on developing and improving national capacity in maternal and perinatal health surveillance in close collaboration with CDC, Atlanta.

In April 1999, an intercountry workshop on developing national capacity in safe motherhood, surveillance and neonatal health was held in Cairo, Egypt, to assess progress made since the 1998 intercountry meeting on safe motherhood, and to develop national capacity in surveillance of maternal and neonatal mortality and morbidity. In preparation, surveys

wereconducted on maternal mortality surveillance systems and family planning programmes in the Region, the results of which were presented at the workshop. The recommendations of the workshop focused on improving the coverage and quality of care of maternal, perinatal and family planning services, with special attention to making better use of data already available in almost all countries, and to strengthening national family planning/birth-spacing policies within the broad context of reproductive health.

In follow-up to the recommendations of that workshop, a regional training workshop on data use and decision-making in maternal and perinatal health care was held in Cairo, Egypt, in November 1999. The focus was on identifying and screening appropriate data sources, managing the limitations of the data and translating the analysis results into programme and policy recommendations. National learning field projects were developed by the participants during this activity and the implementation of these projects is currently being monitored in the participating countries.

A project aimed at introducing the total quality management approach to maternal and perinatal health care was developed and is currently being implemented in collaboration with UNRWA and CDC. Health staff from the five UNRWA field areas and four selected countries were trained as trainers in a workshop held in Amman, Jordan, in February 1999. Eight applied learning projects were developed in the workshop and implemented in the field. A follow-up workshop in September 1999 assessed the outcome of this training activity. A project for initiating implementation of the `Making Pregnancy Safer' strategy in the Region, with special focus on lagging countries, was developed also and will be implemented through a joint plan of action with WHO headquarters.

The Special Programme on Research, Development and Research Training in Human Reproduction collaborated with the Regional Office in responding to the ever growing need for research on reproductive health of adolescents through an intercountry workshop on adolescents' needs and perspectives in reproductive health and how to promote healthy lifestyles among adolescents, which was held in Beirut, Lebanon, in December 1999. The workshop identified future directions for developing and strengthening national reproductive health policies and strategies for adolescents. Generic national research project proposals have since been developed to assess the reproductive health needs of adolescents and will be implemented in collaboration with countries in 2000.

Protection and promotion of child health

Overall progress and achievements

The strategy of Integrated Management of Childhood Illness (IMCI) aims to significantly reduce morbidity and mortality from the most common diseases of young children and to promote their healthy growth and development by improving the quality of child care. IMCI as a strategy is sufficiently flexible that all countries can benefit from some or all of its components, although the focus might differ during adaptation of the strategy to the country's situation and needs. This was the main conclusion of the intercountry meeting organized jointly by WHO and UNICEF in Damascus, Syrian Arab Republic, in July 1999, the first regional meeting at which initial IMCI global and regional/country experiences were presented and discussed with managers from almost all countries. Recommendations were made for further IMCI promotion and implementation through increased partner support. A number of possible IMCI implementation options and priority objectives were identified.

IMCI was introduced to three countries in 1999 (Iraq, Syrian Arab Republic and Republic of Yemen) making the total of IMCI-active countries eight. Two of these (Iraq and Syrian Arab Republic) are in the IMCI introduction phase and six have reached the IMCI early implementation phase (Egypt, Islamic Republic of Iran, Morocco, Pakistan, Sudan and Republic of Yemen). In Morocco and Sudan, review meetings with planning for expansion were conducted, mid-term IMCI planning frameworks and short-term (one-year) plans of action were developed and the support of external partners (WHO, UNICEF and others) secured. During the 1999 Joint Programme Review Missions (JPRMs) there were clear indications of increasing interest in the introduction of IMCI strategy into national health systems: IMCI activities were planned for 2000-2001 in 15 countries.

Building capacity for IMCI

Priority continued to be given to building managerial and clinical capacity for supporting IMCI implementation. A number of key national health managers from Islamic Republic of Iran, Iraq, Pakistan, Syrian Arab Republic, Tunisia and Republic of Yemen were trained in IMCI case management and in facilitator training courses in Egypt, Morocco and Sudan. An IMCI intercountry case management course was also conducted in Alexandria, Egypt, for participants from this and other WHO regions. IMCI orientation sessions and workshops on introduction to IMCI adaptation and planning for national and district staff were conducted in Iraq and Republic of Yemen. An IMCI case management course was also organized jointly by WHO and UNICEF in Iraq to promote knowledge of IMCI content among paediatric opinion leaders. Meetings were conducted in Islamic Republic of Iran, Pakistan and Republic of Yemen with WHO support, aiming to develop national IMCI guidelines by adapting WHO generic guidelines. In the Republic of Yemen, the adaptation process included two nutritional surveys conducted with WHO assistance which resulted in national IMCI feeding recommendations using local terms to improve communication with mothers.

Components of IMCI

With regard to improvement of health workers skills (the first IMCI component), an increasing number of training courses in IMCI facilitation skills and in IMCI case management were conducted at the central level and in the districts in Egypt, Morocco and Sudan with WHO technical assistance. Over 400 doctors and nurses were trained in IMCI case management and the quality of all training courses was carefully monitored and met standard quality criteria recommended by WHO. The breastfeeding counselling training course was introduced in two new countries (Pakistan and Republic of Yemen).

IMCI follow-up after training activities in Egypt, Morocco and Sudan provided sufficient and clear evidence that IMCI produces positive changes in health workers performance, the quality of care children receive and the way health services are organized. Follow-up visits conducted within 1 month after training showed that either all or the great majority of trained health workers had improved their assessment, treatment and counselling skills. This resulted in a very high (over 90%) rate of caretaker satisfaction, as measured through exit interviews of mothers in the health facilities visited.

In addition to introducing and expanding the IMCI in-service training, the Regional Office started to develop IMCI pre-service approaches at the medical school of the University of Alexandria, Egypt. Monitoring of this process conducted with WHO participation showed a high level of IMCI knowledge and skills acquired by the students.

EMRO experience with IMCI early implementation showed clearly that health system improvement in support of IMCI (the second component) is necessary to enable health workers to apply their newly acquired IMCI knowledge and skills when they return to their health facility after IMCI training courses. Status of health facilities and their needs were assessed in all the countries that have introduced IMCI and plans were made to improve health system support to IMCI. In Egypt, Morocco and Sudan, necessary supplies and equipment (IMCI recording forms, IMCI wall charts and mothers' cards) were made available in most health facilities after the initial assessment visits. In addition, in Egypt and Sudan, more rational schemes of patient flow, redistribution of tasks among doctors and nurses, improved child examination areas, new registers for collection of IMCI data and adapted cards for follow-up visits were developed. In all IMCI-active countries plans were made and action taken to improve drug management systems as well as referral pathways for severely ill children and to link IMCI with health sector reform and the national health information system.

Improving family and community practices (the third component) aims to initiate, reinforce and sustain family practices that are important for child survival, growth and development. In Morocco, the one-year experience with the development and implementation of community IMCI showed progress with regard to community assessment and planning, identification of problems to be addressed though baseline and community assessment surveys, development of strategies for community mobilization and involvement in order to promote and support key behaviours and practices for child health; and promotion of intersectoral collaboration towards achieving harmonious psychosocial development of children. There was notable improvement in caretaker satisfaction as well as in the confidence of staff who are now better equipped to manage sick children and to counsel mothers and other caregivers.

In Egypt, the process of planning for IMCI in the community was initiated through a workshop and, as a result, a number of important activities were conducted. These included development of tools for community assessment and baseline surveys, and implementation of the survey in three IMCI operational areas; development of implementation principles aiming to build on existing community-based programmes and structures; and activities aiming to promote local ownership and build up local capacity in order to sustain community participation, ensure partnership between caregivers, community leaders, health workers and other frontline workers, and to extend the vision of the health system beyond the health facility. In Sudan, operational research has started in order to assess factors affecting parents' compliance with IMCI follow-up and referral recommendations.

Protection and promotion of adolescent health

The Regional Office extended increasing support for building up national capabilities in adolescent health and development as an essential component of national health programmes. Close collaboration was maintained with countries, concerned UN agencies and international and nongovernmental organizations. In response to resolution EM/RC43/R.11, and in order to bridge the gap in the knowledge of adolescents, their parents and other concerned partners, a set of regional guidelines on health education for adolescents was developed by the Regional Office in collaboration with the Islamic Organization of Medical Sciences and the Islamic Educational, Scientific and Cultural Organization. The material was designed as three manuals addressed to priority target groups: parents, teachers, mass media and health workers; adolescent girls; and adolescent boys.

A consultative meeting on building national capacity for protection and promotion of adolescent health and development in the Eastern Mediterranean Region was held in collaboration with WHO headquarters in Hammamet, Tunisia, in October 1999. The meeting recommended that the major health needs of adolescents should be identified based on local data and scientific information and in a manner that is sensitive to the religious and sociocultural norms prevailing in the Region. Collection of new data for needs assessment purposes was recommended after an exhaustive review and analysis of existing data. It was also recommended that countries conduct adolescent health strategic planning based on clear goals and measurable objectives. In preparation for the consultation, the Regional Office conducted in mid1999 a survey to assess adolescent health programmes and activities and to determine the measures currently in place to respond to their health needs. Over 50% of the responding countries indicated the absence of a policy or commission geared towards the adolescent population. A salient feature of those countries with an established policy on adolescent health was the emphasis put on the coordination of services across governmental agencies. Information on the health and reproductive health of adolescents, particularly girls, was scanty in the responding countries. Adolescents usually receive health care through the existing health services. The survey confirmed the need to develop a plan of action that will support countries in adjusting their existing policies and programmes to be more receptive to the needs of the adolescent population. In response to the findings of the survey and consultative meeting, a regional project was developed jointly with WHO headquarters for implementation in 2000.

At the country level, the first stage of the district surveys on reproductive health services available for school adolescents in Tunisia was conducted in collaboration with WHO headquarters and the Ministry of Public Health. Some countries, including Bahrain, Egypt and Tunisia, made significant progress in formulating programme policy as well as in implementing strategy. Other countries, such as Islamic Republic of Iran, Syrian Arab Republic, United Arab Emirates and Republic of Yemen successfully implemented adolescent health-related activities, including research and studies on reproductive health of adolescents. Research activities on priority areas of adolescent health including reproductive health are being technically and financially supported in the Region in collaboration with WHO headquarters and through WHO research grants.

Protection and promotion of women's health

Despite the specific attention to women's reproductive health, the protection and promotion of women's health throughout the entire life span has not yet received adequate attention in some countries. During 1999, the Regional Office continued advocating the need for the conduct of nationwide, disaggregated situation analyses of the health of women, in order to identify the major underlying determinants of women's health and thus to establish appropriate national strategies and programmes to promote women's health. In order to support this, the Regional Office started to develop software that will serve as a model for developing women's health country profiles. These diagnostic tools are planned to be field tested in several countries and be ready for use by countries in 2000. An intercountry workshop to strengthen national capacity towards eventual elimination of practices harmful to women in the Eastern Mediterranean Region was held in Sharm El-Sheikh, Egypt, in March 2000. The workshop was aimed at developing regional guidelines to enhance national programmes and activities towards eliminating practices harmful to women with particular focus on female genital mutilation.

At the country level, women's health issues gained increasing support from leadership at the highest level. Recognizing that women's social status, economic productivity and literacy are major contributors to women's health, national intersectoral committees on women's health and development were established in the majority of countries. Extensive efforts were made by these committees to develop national strategies and programmes on women's health and social welfare. Technical assistance was provided to the Islamic Republic of Iran on early detection of breast and cervical cancers, to Saudi Arabia for establishing a national plan of action on women's health, and to the United Arab Emirates in developing a national women's mortality and morbidity surveillance system, while fellowship training was provided to national health staff from Palestine.

Protection and promotion of the elderly

1999 was the United Nations' International Year of Older Persons. Active ageing was the theme of World Health Day 1999 with the slogan `Active ageing makes the difference', which recognizes that older people must go on playing a part in society. In collaboration with Member States, the Regional Office initiated extensive activities to celebrate this important event aimed at advocating the special health and social needs of the elderly in the Region. Advocacy campaigns were conducted with the direct support of senior leadership in several countries including Bahrain, Cyprus, Egypt, Saudi Arabia, Syrian Arab Republic and United Arab Emirates. In response to promotion of the concept of physical activity for the elderly over recent years, about onethird of countries now include physical activity as part of social, cultural and religious programmes for the elderly.

During 1999, the Regional Office conducted a survey aimed at investigating the current national policies, strategies and programmes on health of the elderly in countries of the Region. The survey indicated that national policies for the care of the elderly exist in twothirds of the countries but that special economic opportunities for the elderly population are still needed in the vast majority of countries. The findings of this survey will be published in the Eastern Mediterranean Health Journal in 2000. The Regional Office expanded its technical support to countries in order to further strengthen national strategies and programmes on ageing and health. National guidelines for health care of the elderly were developed in the Islamic Republic of Iran. Advanced local and international training in various aspects of health of the elderly was provided for national health staff in the Islamic Republic of Iran, Lebanon and Syrian Arab Republic. In addition to health education and advocacy, the Regional Office supported an assessment of the health situation of the elderly by the Medical Research Council in Pakistan. The findings of this assessment are expected to guide national efforts in strengthening the programme strategies in the country.

Protection and promotion of occupational health

The Regional Office continued to play its catalytic and promotive role in strengthening national strategies and programmes on occupational health and work safety in the Region; collaborative programmes on occupational health exist in 17 countries. Close technical collaboration was maintained with the Arab Institute for Occupational Health and Work Safety (an affiliate of the Arab Labour Organization and the League of Arab States) as well as other scientific institutions and organizations concerned with occupational health and work safety. The Regional Office provided technical support to the Institute in the conduct of an expert meeting on updating Arabic tables of occupational diseases, held in Damascus, Syrian Arab Republic, in June 1999, and a training course on protection of staff working in phosphate industries, also held in Damascus, Syrian Arab Republic, in September 1999, which were attended by senior experts and national health staff from several countries. Technical support was also provided to the Fifth Pan African Conference on Occupational Health held by the Tunisian Society for Occupational Health in Tunis, Tunisia, in September/October 1999 and the 20th International Mediterranean Conference on Occupational Medicine held by Ain Shams University in Cairo, Egypt, in November 1999. National health staff from several countries were financially supported to participate in these activities.

In order to assist countries in their efforts to integrate occupational services into their national primary health care systems, the Regional Office prepared a training manual on occupational health for health workers. The manual was finalized and reviewed by senior experts in occupational health and is planned to be published in 2000.

At the country level, the Regional Office provided technical support aimed at building up national capacity in occupational health in several countries, including Cyprus, Djibouti, Egypt, Jordan, Islamic Republic of Iran, Iraq, Libyan Arab Jamahiriya, Saudi Arabia, Syrian Arab Republic, Tunisia, United Arab Emirates and Republic of Yemen through consultancy services, national training activities and fellowships.

Promotion of school health

In view of the considerable importance of school health programmes for protecting and promoting the health of children and adolescents during their school years, as well as promoting healthy lifestyles in later stages of life, the Regional Office maintained its technical and financial support aimed at strengthening national programmes and strategies on school health care in countries of the Region. Several countries achieved remarkable success in promoting the national school health care systems through school health insurance schemes and provided excellent models for intercountry exchange of experience in the Region. During the biennium 1998-1999, 13 countries had collaborative programmes on school health care with the Regional Office. National guidelines for school health epidemiological surveillance were developed in Egypt and a survey on school health services was conducted in the Syrian Arab Republic. Local and fellowship training was provided to national health staff in Egypt, Islamic Republic of Iran, Sudan and Tunisia.

Close technical collaboration was maintained with the League of Arab States as well as other institutions and organizations concerned with school health care in the countries of the Region. Technical support was provided to the Arab Council for Childhood and Development in the organization and conduct of the Conference on Raising School Environmental and Health Awareness in Arab States held in Cairo, Egypt, in November 1999. School health experts and programme managers from almost all countries of the Region participated in the conference which concluded with guidelines for reviving school health programmes in Arab States.

Mental health promotion

The main strategy of the mental health programme remains the integration of mental health within primary health care. Technical collaboration in 1999 included consultancies, fellowships, national training activities and workshops, and occasionally provision of essential drugs and supplies. Staff visits were made to evaluate the mental health programmes in the Islamic Republic of Iran and the United Arab Emirates, to take part in national training workshops in the Islamic Republic of Iran, Iraq and the United Arab Emirates, to discuss new initiatives with interested partners in Egypt, to participate in scientific conferences on mental health in Bahrain and Egypt, and to assist in a special evaluation in Kuwait.

An intercountry meeting was held in December 1999 in Alexandria, to evaluate the progress of the national mental health programmes in the Region and to develop a set of indicators for future programme evaluations. A review of the mental health situation in the Region entitled `Reaching the unreached: strengthening mental health programmes in the countries of the Eastern Mediterranean Region' was finalized and is due to be published in 2000. The Regional Office collaborated with a number of interested countries, including Bahrain, Egypt, Islamic Republic of Iran, Pakistan and Tunisia, in further development of school mental health and life skills education programmes. The Nations for Mental Health programmes in Egypt and the Republic of Yemen continued, and in Egypt the first stage of this programme was completed.

Prevention and control of substance abuse

Reports, both official and unofficial, of the increasing problem of substance abuse in the Region were the major concern in 1999. This increase was also associated with reports of a gradually increasing tendency for injecting drug use and the associated danger of needle sharing and transmission of HIV/AIDS. A number of rapid assessment studies (in Egypt and Islamic Republic of Iran) highlighted these new trends, which by no means are limited to these countries. To assess the situation and discuss possible preventive interventions, an intercountry meeting on demand reduction for substance abuse with special emphasis on injecting drug abuse, was held in Beirut, Lebanon, in November 1999. This meeting was held in collaboration with UNAIDS, UNDCP, WHO headquarters and the AIDS and sexually transmitted diseases programme in the Regional Office. The meeting provided a much clearer and more realistic picture of the extent of substance abuse and injecting drug use in the Region and resulted in a number of recommendations for countries.

Tobacco Free Initiative

The Tobacco Free Initiative programme gathered momentum during 1999, in line with its progress elsewhere. The progress report submitted to the Forty-sixth Session of the Regional Committee generated extensive discussion, reflecting the great importance now attached to tobacco control both at country and regional levels. There is obvious need for more proactive cooperation between countries and the Regional Office in developing fully integrated plans of action that address the different aspects of the tobacco problem.

A regional meeting held at the Regional Office and attended by 21 countries looked at the steps needed for more vigorous action at country level to combat the spread of tobacco consumption. This outlined a number of highly relevant actions that need to be taken in the legislative, educational, information and taxation fields. A general review of the regional plan of action, developed in a special consultation held in 1995, was carried out. The revised plan of action was approved by the Regional Committee.

Participation by countries of the Eastern Mediterranean Region in global activities for the Framework Convention on Tobacco Control was not as encouraging as it could have been. Only 10 countries attended the first meeting of the Working Group held in Geneva in October 1999. An even smaller number participated in the Delhi Conference on Tobacco and the Law in Developing Countries. Similarly, participation in the Kobe conference on Women and Tobacco was quite poor. There are several reasons for this, including the timing of the Delhi Conference and the lack of a clear perception of the aims of the working group. It is hoped that participation in the second meeting of the Working Group will reflect the interest of the Region in the tobacco problem.

Surveys were carried out in two countries (Jordan and Oman) on Tobacco and Youth. More surveys are being planned in other countries during 2000. These should cover such areas as tobacco use among health professionals and the increase in the number of women smoking.

More countries allocated funds during the Joint Programme Review Missions for tobacco control activities. It is hoped that this will result in more forceful action in this very vital area of health work. Some countries have taken action to strengthen legislative measures aimed at restricting tobacco use among young people and in public places. However, the Region still lags far behind developed countries in this area. Such measures are vitally important in raising public awareness of the need to restrict tobacco use and in generating a social climate which is hostile to smoking. Plans are being prepared at the Regional Office to study measures that can be taken to enforce existing laws and regulations aimed at restricting tobacco use. It is hoped that this will help countries in putting into action what has already been promulgated.

Capacity-building is an important issue in tackling the tobacco problem. This is true both at the regional and national levels. It is hoped that all countries will move forward in this regard during 2000. At the Regional Office a new Tobacco Free Initiative unit has been established, headed by a Regional Adviser. A Technical Officer was appointed with a special interest in the legal aspect of the tobacco problem and a second Technical Officer was appointed at the beginning of 2000 for media activities in respect of tobacco control. This gives the Regional Office a strong unit to help countries in their various needs in this area.

The religious aspect of the tobacco problem, which was highlighted by the Regional Office more than 10 years ago, has generated interest in other regions. Demand has increased for copies of the regional publication Islamic ruling on smoking. A new edition of this book is being prepared with the views of more scholars included. A similar ruling has been requested from Christian religious authorities.

Health education (including school health curriculum)

Health education activities in the different countries of the Region focused on exploring innovative ways of ensuring effective health education through the collaborative programmes with countries.

In Afghanistan, efforts to disseminate relevant information to different communities through a well recognized medium continued. The BBC radio series New home, new life, developed with technical support from WHO, increased its themes to include gender issues and rights as well as domestic violence, complementing health workers' efforts in health education for those who use the health care system.

The action-oriented school health curriculum is still the main entry point for health education of schoolchildren. The prototype was adapted in a number of countries in 1999. In Lebanon, an innovative educational methodology was launched in collaboration with the National Centre for Educational Reform and Development, Ministry of National Education, Youth Guidance and Sports. Based on a `spiral curriculum' which introduces health education topics in stages according to age, the methodology has been developed through an integrated approach, to enhance cognitive, affective, and psychomotive skills. Areas covered by the health education curriculum for pre-university students include personal hygiene, accident prevention, food and nutrition, prevention of diseases, oral health, smoking, drug addiction, gambling, alcohol and sexually transmitted diseases.

In the Syrian Arab Republic, six governorates have launched the Community School Initiative which promotes interaction among schoolchildren, teachers and community. The initiative is based on learning-by-doing, through observation, information gathering, debate, identifying strengthens and weaknesses, partnership, self-learning, team work and life skills development. The impact of such an initiative has been evident in class rooms and in the community. The success of the initiative owes much to political commitment; inclusion of the action-oriented school health curriculum by the Ministry of Education as an essential component in the school programme; and infrastructure development through capacity-building of national categories, e.g. training of trainers, instructors and school health physicians (for four days) who in turn train school teachers on specific topics assigned to the different classes.

Iraq adapted the prototype into three volumes, each covering one elementary year, while the Republic of Yemen adopted the curriculum as a guide for the fourth year of elementary school. In Egypt, the Ministry of Education in collaboration with WHO and UNICEF produced an educational package to develop environmental and health awareness for the age group 6-12 years. The kit includes a resource book, activities book, charts, stories, posters, games and material for parents. In Sudan, use of the curriculum was expanded to cover more schools in five states.

A number of activities took place to build up national capacity in health education. In Jordan, health education coordinators were trained in three governorates to strengthen the Departments of Information and Education for Health. In Sudan, health workers were given training to improve their performance with regard to priority health problems, such as acute respiratory infections. In the Republic of Yemen, the WHO Collaborating Centre on health education received support to upgrade the skills of staff in the Centre, as well as audiovisual aids. In Lebanon, an agreement was made with the American University in Beirut to support health education programmes and establish links between academic institutions and the health care delivery system. WHO also supported behavioural research in school health education and development of a protocol for qualitative and quantitative studies on students' health behaviour.

National policies in support of health education and with particular reference to the action-oriented school health curriculum were formulated in Egypt, Djibouti, Islamic Republic of Iran, Iraq, Sudan and Syrian Arab Republic. In the Islamic Republic of Iran, the Secretariat of Public Health was given a mandate to develop the health promotion strategy of the Ministry of Health and Medical Education. The key role of this Secretariat is to prepare a strategic plan for health promotion which will identify: the place of health promotion within its overall national development and specifically health, goals; the role of key agents in health promotion including behvarz, doctors, teachers and provincial staff; and the role of a national level resource for health promotion that might provide a coordination, training and technical support role.

Iraq is currently reorganizing the Health Education Department to be more integrated and coordinated with other departments in the Ministry of Health. The Federal Ministry of Health in Sudan has drafted a new national health education policy to promote the health of the community, based on evaluation of the current situation regarding health education policy and strategy. Many countries in the Region produced and disseminated educational material in different areas of interest to the public and to health facilities: for example, Oman and the United Arab Emirates produced material on smoking and sexually transmitted diseases; Egypt produced material on occupational hazards; and Iraq produced television spots on iodine deficiency, neonatal tetanus, diarrhoea, AIDS and smoking.

Collaboration with ISESCO achieved a lot in 1999, reflecting a partnership that is benefiting countries both inside and outside the Region. This included translation into English of books on malaria, drug addiction and AIDS and development of posters. ISESCO, together with other national and international organizations such as UNFPA, also supported capacity building of key officials from different disciplines and sectors through several workshops. WHO also collaborated with UNESCO/UNICEF in the Education for All Conference, which was attended by Arab Ministries of Education and highlighted school health and nutrition.

Promotion of healthy lifestyles

The shifting trend in major causes of disability, morbidity and mortality worldwide towards predominantly non-infectious chronic diseases which have their origin in human behaviour, such as smoking, unhealthy food habits, lack of physical exercise, violence, accidents, substance abuse, unsafe sexual behaviour and stressful lifestyles, means that investment in healthy lifestyles is the most cost-effective and human intervention to ensure well being and quality of life. Lifestyle patterns have not yet been well studied and documented in the Region and this places a major limitation on developing healthy lifestyle policies, strategic plans and programmes. The Regional Office is promoting development of a risk behaviour assessment database, and some countries are starting their initial assessment in 2000. The database can then be used as evidence in developing appropriate approaches based on best practices. The Regional Office is promoting two main directions for healthy lifestyle programmes: identification of the main determinants of health and identification of the right setting for health promotion, whether that be schools, homes or health facilities, for example. Collaborative programmes in 2000 will gather baseline data on the major determinants of health and risk factors which will enable them to assess the magnitude of the problem and the possible entry points to address these problems. A manual on healthy lifestyle promotion was prepared by the Ministry of Health, Syrian Arab Republic for use by health workers and the community in the healthy villages, as well as in other settings.

The health-promoting schools approach was introduced to the Region with the launching of the prototype action-oriented school health curriculum (PAOSHC) in the late 1980s; 17 countries have adopted the PAOSHC in different forms. Recently the Syrian Arab Republic introduced the concept of community schools in six governorates with high level commitment. The initiative is being institutionalized through inclusion in the national education plan, training of training teams and schoolteachers, with supervision and coordination from both the Ministries of Education and of Health. Community schools introduced into healthy villages have been shown to have a more conducive environment and to produce better results. In Oman three components of the health-promoting schools approach (school health services, health education and school health environment) were implemented in several schools. In some wilayat the Wilaya team problem-solving techniques were instrumental in mobilizing schools to solve a common health or disease problem, either within the school or in the community.

Safety promotion

Injuries, whether intentional or non-intentional such as those resulting from traffic accidents, are becoming major causes of disability, morbidity and mortality worldwide and in the Region. It is already known that injuries are a leading cause of morbidity and mortality in several countries of the Region. In Egypt, it is the fifth leading cause of death in both males and females. In the Islamic Republic of Iran accidents and injuries are the second leading cause of death. In the Libyan Arab Jamahiriya accidents account for 15.5% of the gross mortality rates, while in Pakistan up to 100 000 people die every year as a result of accidents. In many other countries accidents, injuries and poisoning rank among the first five causes of all deaths.

Some countries, appreciating the social, economic and health burden relating to injuries and accidents, have embarked on research (Egypt, Jordan, Lebanon and Syrian Arab Republic) and structural development (such as the National Committee for Safety Promotion and Accidental Injury Prevention established in the Libyan Arab Jamahiriya). Some countries have already launched important entry points to address this major public health problem. In Egypt, a surveillance system for the collection of injury information from emergency departments is in operation. Preliminary findings from examination of 255 of the expected 200 000 injury reports from 6 governorates indicate that fights account for nearly 40% of emergency visits, with females accounting for about 40% of these, and road traffic accidents for 25% of emergency visits. At least one-fifth of the injuries are serious. Efforts to improve data management and analysis as well as quality control have started and need to be strengthened further. Information dissemination started in 1999 with the production of nine posters and a leaflet on different types of injuries to be disseminated to the public and to health institutions.

In Jordan a pilot study on domestic injuries among children under 5 years, in collaboration with the Ministry of Health, showed that, among the population studied, falls accounted for 60.6% of injuries, collisions at home 9.7%, burns 6.4%, poisoning 6.1% and fighting 3%; 84.6% of injuries occurred inside the house, and the majority (49%) in the afternoon. Injuries increased with age and were higher among male children (61.6%) than female children (38.4%). The city children were exposed to more injuries (71.3%) than rural children (28.7%). Accidents were more frequent when the mother was not working. Accidents were least frequent among children of illiterate mothers and highest among those whose mothers had finished secondary education. Further analysis of these results and the related factors will be undertaken.

In the Syrian Arab Republic there is an information system for all types of accident, based on data collected from the health centres, emergency units and hospitals. All health centres and about 90% of the public hospitals participate in the registration. The Ministry of Health is considering developing a minimum basic data set as a complementary accident information system, which will gradually and periodically be expanded. Preliminary data show that occupational accidents account for the most injuries (33%) followed by domestic and leisure accidents (29%); road traffic accidents accounted for 8%. In all the 14 provinces and as part of the national safety promotion programme, there is one doctor and one health educator appointed to work with registration and prevention of accidents. Other countries have opted to develop national capabilities in safety promotion (Cyprus, Islamic Republic of Iran and Lebanon) by providing training locally or abroad of key Ministry of Health staff.

Oral health promotion

The oral health programme launched an important database initiative in 1999 in collaboration with the Regional Demonstration, Training and Research Centre in Oral Health in the Syrian Arab Republic. The database will enable proper assessment of the regional situation with regard to oral health problems, namely dental caries and periodontal diseases, and of the national infrastructure supporting oral health. Analysis of the data so far shows that the DMFT index for decayed, missed and filled teeth among 12 year-olds has improved in a few countries, but has worsened in many other countries, which apparently need more comprehensive oral health care programmes. Figure 4.1 shows the dental caries situation in some countries of the Region.

Study of the data also indicates that, despite availability of dentists in some countries, there have been no improvements in oral health indicators. This is explained by the fact that most of the efforts of such human resources are focused on clinical rather than preventive oral health. Some of the data reported goes back to early 1990, which means there is an urgent need to update the data. Pre-school decayed teeth account for an alarming percentage of the deciduous teeth in some countries.

Dental caries is caused by unhealthy lifestyles, especially high intake of sugar foodstuffs and lack of oral hygiene and fluoride. The situation calls for organized oral health programmes based on prevention, oral health promotion and greater use of the atraumatic restorative treatment (ART) technique. As well as an oral profile for each country, the database provides a regional oral health profile, which will highlight future directions for oral health care.

ART as a strategy for oral health care is gaining acceptance in the Region. The Islamic Republic of Iran, Lebanon, Sudan and the Syrian Arab Republic are among the first countries to implement the ART strategy on a national scale.

Several countries launched oral health education in different forms. The Islamic Republic of Iran produced 10 films for television focusing on prevention and hygiene for different age groups. In the Syrian Arab Republic a comprehensive oral health education programme is implemented through the school health curriculum. In Sudan a variety of oral health education materials were prepared for the public, health facilities and health institutions.

Building up national capacity has become a major aspect of WHO's partnership with countries. The Syrian Arab Republic is preparing training modules for dental auxiliaries on up-to-date and appropriate oral health techniques, in collaboration with the Regional Demonstration, Training and Research Centre in Oral Health. The centre also held training courses in dental public health for dentists from the Region and produced educational materials, such as guidelines for health workers, videos and posters, for the Region.

Fluoridation of salt or water is an important strategy for prevention of caries, especially among young children. Lebanon, a country with low fluoride concentration and a high DMFT index, has opted for nationwide salt fluoridation through a national project supported by WHO, UNICEF, the University of Texas, USA, and the Faculty of Dentistry, American University in Beirut, Lebanon. The Syrian Arab Republic undertook fluoride mapping in all the cities in collaboration with Zurich University.

The curricula of the faculties of dentistry of the University of Sana'a, Republic of Yemen, and Khartoum, Sudan, were reviewed by experts within and outside the Region, promoting the concept of networking and sharing of experience.

Disability prevention and rehabilitation

In addition to regular collaboration with the countries of the Region, a major intercountry workshop on community-based rehabilitation was held in Teheran, Islamic Republic of Iran, in October 1999, in collaboration with WHO headquarters. Each of the participating countries produced a national plan of action to be used as a model for development of future programmes.

Promotion of healthy nutrition

Nutrition surveillance and management of nutritional problems

Nutritional status is an outcome of a wide range of social and economic conditions and is a sensitive indicator of the overall level of development. Generally, assessment of that status will include evaluation of nutritional indicators various population groups, and of the trends in those groups. The Regional Office provided support to Bahrain, Cyprus, Djibouti, Iraq, Libyan Arab Jamahiriya, Pakistan, Palestine, Saudi Arabia, Sudan, Syrian Arab Republic and Republic of Yemen in order to develop and strengthen their national capacities in preventing and controlling protein-energy malnutrition and micronutrient deficiency. Technical assistance was also provided to Qatar to conduct a nutritional survey of adolescents. The national database and the information system on nutrition was updated in Cyprus, Kuwait, Pakistan and Syrian Arab Republic with input from the Regional Office.

Micronutrient deficiencies

In recognition of the seriousness of iodine deficiency disorders (IDD), 16 countries have now adopted IDD control through the iodization of salt and activity towards universal salt iodization (USI) was maintained during the reporting period; in 1999 seven countries reported USI while Bahrain, Islamic Republic of Iran, Jordan and United Arab Emirates have incorporated USI monitoring into their food control activities. The Regional Office assisted Jordan, Palestine, Pakistan and Sudan in further developing their national strategies for the control of IDD. In Pakistan, a training workshop on quality control to maintain safe limits of potassium iodate and quality of salt was supported by the Regional Office. Countries have improved their information systems on the prevalence of IDD. The Islamic Republic of Iran has approached the Regional Office to declare the country IDD-free. An intercountry symposium-workshop on assessment and monitoring of IDD was held in Teheran, Islamic Republic of Iran, in September 1999. The objectives were to review progress made in IDD control in the Region and discuss IDD control programme monitoring and evaluation. International organizations represented included the International Council for the Control of IDD, the Micronutrient Initiative (MI) and UNICEF. Participants recommended the establishment of a regional training capacity for IDD monitoring in the Islamic Republic of Iran.

With regard to iron deficiency anaemia, the Micronutrient Initiative fund, established in 1998, became operational in mid-1999. This fund, which is administered by the Regional Office, involves close cooperation between MI, UNICEF and WHO. The fund exists to address obstacles to the implementation of flour fortification with iron and folate, and to assist in initiating national flour fortification programmes. By the end of 1999 eleven technical missions had been arranged through the Regional Office to countries, in order to assist in the finalization of proposals for submission to the fund. Six countries (Egypt, Islamic Republic of Iran, Jordan, Lebanon, Pakistan and Republic of Yemen) have received funds and started implementing their programme; five more countries (Bahrain, Djibouti, Iraq, Morocco and Oman) are in the process of finalizing proposals. Two proposal review sessions were arranged, which were attended by review board members of MI, UNICEF and WHO.

As part of the activities of the MI-fund, a mission was arranged for a visiting professor from Oman to Canada, to study the technical possibilities of fortification of edible oil with vitamin A to combat vitamin A deficiency.

Health and diet

A number of countries have noted their concern about the increases in obesity and other conditions related to excessive or unbalanced food intake, such as diabetes, hypertension and cardiac problems. The high prevalence of obesity, particularly in women, and its onset during adolescence, has been documented for several countries. Food-based dietary guidelines have been developed in Bahrain and Kuwait and a national strategy document on the prevention and control of diet-related chronic diseases was prepared in Bahrain. Training in dietary management of noncommunicable diseases was organized in Kuwait and Oman. Several countries (Oman, Pakistan, Syrian Arab Republic and United Arab Emirates) participated in a workshop on a management information system for emerging foodborne diseases. An innovative approach, called a `town-storming seminar', was adopted in Pakistan to promote a healthy lifestyle through healthy nutrition, and primary health care workers in Saudi Arabia were trained in educating the public in healthy dietary habits. Assistance was also provided to Lebanon and the United Arab Emirates to develop nutrition education materials.

The Regional Office organized an intercountry workshop on the prevention and control of obesity in Bahrain. Representation from international organizations included the International Obesity Task Force. The workshop introduced the new approach of `environmental auditing', looking at the opportunities and constraints for reducing energy intake and increasing energy output in different settings.

Infant and child feeding

Infant and child feeding is a complex issue. While breastfeeding promotion continues in all countries, several countries have shown interest in complementary feeding programmes and requested assistance from the Regional Office. The Ministry of Health and Population of Egypt requested assistance to develop a comprehensive strategy on infant and child feeding and nutritional social marketing of correct complementary feeding. Djibouti requested technical assistance in the development of a strategy for infant and child feeding and development of low-cost fortified complementary food.

Regional nutrition training

The sixth training programme in nutrition was completed during the year. Nine participants took part from five countries, seven of whom were funded by WHO. A consultant recruited by the Regional Office evaluated the training programme, funded by the Government of the Netherlands. In addition, decentralized nutrition training programmes have been initiated in Egypt, Palestine and Sudan. The seventh regional training programme started in February 2000.

Promotion of food safety

A technical paper on food safety was presented to the Forty-sixth Session of the Regional Committee, which discussed the increase in foodborne illnesses and the economic impact of poor food safety. New challenges to food safety were highlighted, such as the emergence and re-emergence of pathogens, new agreements in world trade and the new role of the Codex Alimentarius Commission in this regard, and emphasis was put on the use of the system of hazard analysis critical control point (HACCP) as a preventive approach, and of risk analysis as a scientific method. A regional action plan to address food safety in the 21st century was adopted in resolution EM/RC46/R.6.

The delegates agreed on the need to assess their current food safety infrastructure at national level and prepare comprehensive country profiles for food safety. They also agreed to establish or strengthen the national food safety committee or similar body, and make it operational to implement the national food safety programme. It was also agreed that legislation should be developed and kept up to date in accordance with the latest scientific developments, and that preventive food-safety management systems based on HACCP should be promoted.

In immediate response to this important resolution, a regional workshop was held in Dubai, United Arab Emirates, in December 1999, in which participants from almost all countries in the Region discussed the implications of new challenges to food safety in their countries. The regional action plan was introduced and the first step of the plan, assessment and review of the national food safety situation, was initiated. One of the recommendations of the workshop was to finalize the assessment and review in all countries within a period of 6 months after the meeting. In December 1999, a web page was launched on the EMRO website in response to another recommendation of the workshop, providing information on WHO activities in food safety, as well as links to useful institutions.

Management of water supply and sanitation

Population pressure has already placed a severe load on scarce water resources in the Region and as the standard of living of the population increases, so per capita demand for water will increase further. Countries have exerted a sincere effort to increase water supply coverage, however, water scarcity and high costs act as formidable barriers to progress. In

the least developed countries, especially, monumental tasks lie ahead to provide everyone with safe and easily accessible water.

The problem of water scarcity has become the focus of many regional conferences sponsored by United Nations agencies, multilateral organizations and regional bodies concerned with water and development. It has now become imperative to address the issue of `drinking-water security'. In the meantime, as more and more countries in the Region have to rely increasingly on water desalination and the use of non-conventional waters, more attention is being devoted to the technical and economic aspects of water desalination.

An emerging issue for water supply in the Region is the intermittent supply of water to consumers, which has come about as the result of water scarcity, rapid urbanization, the high cost of expanding systems, as well as other factors. Since intermittent water supply has become almost a norm in many countries, greater attention is required to address the potential for contamination and the health hazards of such a system of water delivery.

In collaboration with WHO headquarters, UNICEF and the United Kingdom Department for International Development (DFID), the status of water supply and sanitation in the Region was assessed as part of the Global Water Supply and Sanitation Assessment 2000. As part of this exercise, questionnaires were sent to almost all countries and the results of other major surveys and assessments gathered also.

The work of the Inter-Agency Task Force (IATF) on Land and Water Resources progressed and the Near Eastern Regional Office of FAO finalized the users manual on wastewater reuse at farm level. The Regional Office and CEHA reviewed it and provided input. Water resources assessment and consolidation of water resources data by different agencies and institutions, along with wastewater reuse, are the current focus of IATF.

In spite of difficulties due to civil strife, the water supply and sanitation programme in Afghanistan continued to progress, assisted by UNDP, UNHCR, UNOCHA, UNICEF, the Qatar Charitable Society and the Kuwait Red Crescent Society. WHO Regional Office staff, national engineers, consultants and temporary advisers assisted Afghanistan, Islamic Republic of Iran, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Qatar, Sudan, Tunisia and Republic of Yemen in a wide range of areas, including drinking water quality, planning and implementation of water supply and sanitation, low-cost sanitation, hospital sanitation, monitoring and information provision. Assessment of these activities indicates a crucial need for much greater financial support by the donor community for water supply and sanitation in Djibouti, Pakistan, Somalia, Sudan and Republic of Yemen.

CEHA allocated over half of its 1998-1999 biennial resources and activities to water supply and sanitation. Two national training courses promoting sanitation and safe wastewater management were supported in Afghanistan. A series of national seminars on environmental sanitation were supported in Morocco. Assessment of the needs and priorities of the sanitation sector was undertaken in Egypt, Sudan, Syrian Arab Republic, Tunisia and Republic of Yemen. The outcome of these assessments provided a basis for designing the regional initiative for sustainable sanitation and wastewater management for small communities in the Region. CEHA also provided support to the Islamic Republic of Iran to establish a training course at the University of Teheran on the principles of wastewater management for small communities. With regard to the safety and health aspects of wastewater reuse, CEHA continued the implementation of its joint regional project with the Arab Fund for Economic and Social Development (AFESD). Activities included: a regional training course for trainers and development of a guide on detection and enumeration of nematode eggs in influent, effluent and sludge; compilation of country profiles on wastewater management and reuse in three countries and initiation of the process in seven other countries; two national training courses on health aspects of wastewater reuse in Jordan and the Syrian Arab Republic; and two troubleshooting and assessment missions for wastewater management and reuse for Oman and the Syrian Arab Republic.

Management of healthcare waste is another emerging environmental health priority that is receiving increasing attention in the Region. WHO staff and consultants assisted national authorities in solid and hospital wastes management in Kuwait, Libyan Arab Jamahiriya, Saudi Arabia and Republic of Yemen. More than 1000 copies of the WHO publication Safe management of wastes from healthcare activities were reprinted by CEHA and arabization of a training video on health care waste management was initiated and will be completed in early 2000. In Jordan, CEHA provided technical assistance to international organizations as well as government institutions and participated in several national projects dealing with hazardous waste and medical waste management. A special initiative was undertaken in collaboration with Gesellschaft für technische Züssamen (GTZ), Germany, the Jordan Environment Society and the Ministry of Health to promote safe management of healthcare wastes. It is planned to produce appropriate training materials and train hospital staff on appropriate procedures for collection, separation and disposal of such hazardous waste.

Promotion of healthy cities, villages and communities

In response to the challenges of rapid urbanization, the healthy cities programme has forcefully promoted an integrated approach to health, environment and quality of life in urban areas. The programme continues to attract sustained interest and popularity among the national and city authorities in the Region. More and more cities are joining the healthy cities network. The programme is expanding in the Islamic Republic of Iran and it is encouraging that new cities are seeking to apply the healthy cities concept and approaches. Two more cities in Palestine, Gaza and Nablus, embarked on healthy cities projects. In Iraq, a well prepared healthy cities and healthy villages programme was launched. In the first healthy cities project, in Gharaghoush, a detailed plan of action was prepared and a committee with representation from the People's Assembly, the health sector, education, the Women's Federation and the Municipality was formed. The healthy cities programme in Beirut, Lebanon, has commenced and plans are under development to start the activities in collaboration with the American University in Beirut. In Saudi Arabia, following the successful launching of the healthy city programme in Al Bukariya, the programme is expanding to other cities. As a result of the successful work there, AGFUND has provided substantial support for healthy cities in the countries of the Gulf Cooperation Council.

The healthy cities and women's development project is expanding rapidly in Egypt. The Regional Office's sponsored project approach has gained popularity in many communities in Egypt. Following the successful implementation of the project in informal settlements in the East District of Alexandria, a more substantive project, supported by the Governor of Alexandria, has started in the town of Abu Qir. The project is concentrating on community cleanliness, a healthy hospital and awareness-raising with the full participation of women in community development. Also, supported by catalytic funds from UNDP, a significant clean-up campaign is being developed in the East District of Alexandria. There is keen interest in expanding the project in other areas in Egypt and other countries.

The ongoing healthy city project in Jalalabad, Afghanistan, is pushing forward. The activities are progressing well within the main themes of sanitation, community cleanliness and food safety. Healthy cities activities in Cyprus and Tunisia continued, while plans are in the making to implement the projects in Djibouti and the Republic of Yemen.

Similarly, healthy villages projects are rapidly expanding. An Inter-Regional Healthy Village Technical Consultation was held in Damascus Syrian Arab Republic in October 1999. The meeting reviewed the technical guidelines for healthy villages being produced by WHO headquarters and discussed health services, environmental services, water resources, community organization and participation, information, emergency, income generation and food security. Accordingly, wide-ranging recommendations were put forward.

In the Islamic Republic of Iran and the Syrian Arab Republic programmes continue to grow, while a healthy villages programme was launched in Iraq, starting with two communities. In Afghanistan, the healthy villages activities progressed in Kandahar, Faizabad and a number of other areas. An extensive programme has been planned for 2000-2001 in Jordan. Healthy villages projects are under consideration as part of the joint activities of the Inter-Agency Task Force on Land and Water Resources in the Republic of Yemen with collaborative support from WHO and FAO.

In view of the huge demand for technical support, massive fund raising efforts have been undertaken. Extra funds are needed for seed support to cities as well as to enable WHO to provide technical advice through its expertise and staff resources.

Environmental health risk assessment and management

The objective of this specific programme is to achieve a sustainable environmental basis for health for all, to provide an environment that promotes health and to make all individuals and organizations aware of their responsibilities for health and environment.

Significant progress was made in the initiative to support countries in the completion of their plans of action for health and environment. Only a few countries have now not started the exercise in that regard. Countries where the process had stalled have resumed it (e.g. Oman) while others have initiated it (e.g. Kuwait and Qatar). Other countries have integrated the health component directly into their national plans for health and environment (e.g. Djibouti). In one country (Morocco), the complete planning exercise was carried out, from identification of priority environmental health actions to their actual inclusion in the country mid-term plan for economic and social development. In that case, the option of choice was to include environmental health considerations in the national plan for the environment, which is itself part of the national process for planning for sustainable development.

CEHA's efforts at building up technical capacity for environmental health impact assessment (EHIA) of development projects continued with a regional workshop in Amman, Jordan, for the Arabic-speaking countries. Based on the output and recommendations of two earlier workshops in Jeddah, Saudi Arabia, and Tunis, Tunisia, a series of national seminars on EHIA were held in the Region. The regional and national activities enabled a review of the state of EHIA in the Region, and provided opportunity for the introduction of current thinking on technical, policy and other requirements for effective national implementation of EHIA. CEHA is in the process of finalizing regional guidelines on EHIA, in collaboration with international partners. All these activities were carried out with financial support from the IDB, and because of the importance of EHIA, IDB and AGFUND approved two new projects to further support its promotion in the Region.

Regarding drinking-water quality, WHO efforts not only concern the setting of guidelines and standards, but extend to the promotion of the application of national standards, through monitoring and surveillance, in order to improve quality and correct urgent situations affecting health. Translation into Arabic of volumes 1 and 3 of the second edition of the WHO drinking-water quality guidelines was completed in 1999. Strengthening drinking-water quality surveillance and monitoring systems was a priority for CEHA. Two national seminars and training courses were convened, in Iraq and Palestine. In Oman, CEHA staff undertook an assessment of the national system for surveillance and monitoring and a plan of action was developed. In response to a request from the Government of Jordan, CEHA participated in the meetings of the national committee on drinking-water quality and health and provided technical support. CEHA also advocated for integration of drinking-water quality standards into the national environmental standards at an ESCWA regional meeting on the subject.

In some countries of the Region, desalination plays a major role in meeting water demand. A technical advisory mission to a country of the Gulf Cooperation Council confirmed the need for guidelines regarding water quality aspects of desalination at different stages of the process. With regard to the preparation of guidelines on water quality aspects of desalination, in collaboration with WHO headquarters, UNEP's Regional Office for West Asia and ROPME, the National Sanitary Foundation (International), the WHO collaborating centre for water safety and treatment, prepared a background paper on the process for the Regional Office. This document presents the situation regarding water quality aspects of desalination and proposes a draft plan of action for developing global guidelines that would provide authoritative reference review and assessments, basis for decisions, and good practices in matter of design and construction for desalination facilities. A planning consultation on the matter is planned with the financial support of AGFUND.

The Regional Office embarked on a significant set of collaborative activities regarding control of industrial pollution in the Libyan Arab Jamahiriya, including training on rapid assessment techniques for the evaluation of industrial pollution and support to data management for decision-making.

Cooperation with other regional and international organizations included a joint training workshop on medical preparedness and medical care in case of radiological emergencies held in collaboration with the Arab Atomic Energy Agency (AAEA) in Cairo, Egypt, November 1999. A joint coordinating meeting was also held in Cairo in November 1999, to prepare the work of national teams in charge of implementing a joint project on accumulation of radon in houses in six Arab countries (Egypt, Jordan, Libyan Arab Jamahiriya, Saudi Arabia, Syrian Arab Republic and Tunisia). The AAEA will study the funding requirements of the national projects proposed during the meeting. Following approval of the AAEA Executive Board, WHO will discuss further cooperation.

The Regional Office also participated in the training course on environmental management in industry organized jointly by the League of Arab States, the Arab Labour Organization, the Arab Organization of Industrial Development and Mining, and UNEP's Regional Office for West Asia, held in Abu Dhabi, United Arab Emirates, in May 1999, to ensure health considerations are taken into account in this rapidly developing area.

Following the restructuring of the Regional Office, the environmental health risk assessment and management programme was divided into: environmental health policy, covering policies, strategies and plans of action for health and environment and related activities; and environmental health risk assessment, covering the various technical areas. The collaborative programme with countries for 2000-2001 was prepared following this new delineation. It is also worth noting that 2000-2001 will be the first biennium covered by the plan of action for health and environment in the Eastern Mediterranean Region, endorsed by the Ministerial Conference on Health and Environment, held in Damascus, Syrian Arab Republic in December 1997.

Promotion of chemical safety

The regional programme for the promotion of chemical safety continued to give priority to strengthening of capabilities and capacity at the country level. In Sudan two national training courses on safe use of pesticides were conducted; 30 nationals were trained in follow-up to previous courses. A national workshop also trained 30 nationals in the prevention and control of poisoning. In Pakistan, eight training courses were conducted in major cities on various aspects of safe management of chemicals for 160 workers. The Islamic Republic of Iran, Saudi Arabia and Sudan received support to prepare national guidelines on safe use of pesticides in local languages.

A coordination meeting of all the stakeholders was held in Bahrain to initiate the process of preparation of the national profile on chemical safety (NPSC). Staff members from various concerned ministries participated in the process of profile preparation as equal partners. Technical support was also provided to Bahrain, Cyprus, Islamic Republic of Iran, Kuwait, Lebanon and Sudan who are already in the process of NPCS preparation. CEHA conducted national training on establishing national chemical safety profiles in Islamic Republic of Iran, Jordan and Morocco. In order to support countries in information exchange on toxic chemicals and risks from these chemicals. Egypt, Lebanon, Morocco and Oman were provided with computerized databases on hazardous chemicals and internationally evaluated risk assessments on these chemicals.

As a result of technical support to countries, Bahrain strengthened its activities concerning safe management of radioactive waste; Iraq strengthened its national register for chemicals and plans were made for an inventory of toxic and hazardous chemicals; Jordan prepared computer software for the establishment of a national register of toxic and hazardous chemicals; Oman prepared plans to develop a poison information and control centre; and plans for the development of a national programme for the safe management of chemicals were prepared for Pakistan.

Under the regional initiative on safe management of chemicals, especially pesticides, the Islamic Republic of Iran prepared guidelines and a manual and Morocco prepared brochures and leaflets on safe management of chemicals. Saudi Arabia and Sudan prepared national guidelines on safe use of pesticides. With regard to chemical risk reduction activities, technical assistance was provided to determine the production, export and use of persistent organic pollutants (POPs) in countries. Five countries reported the use of pesticides included in the list of 12 POPs which are under review for elimination. CEHA is producing a video film on safe use of pesticides which will be ready for distribution in 2000.

Vector control

Despite considerable progress in technology, vector-borne diseases such as malaria, leishmaniasis, schistosomiasis, filariasis, salmonellosis and rodent-mediated diseases such as plague, are still of major public health concern. Diseases caused by arboviruses, such as dengue and haemorrhagic fever, also continue to make surprise appearances in some countries.

Shortage of trained and expert personnel in this field is the most prominent constraint in prevention and control of these diseases. In collaboration with a number of research institutes and universities within and outside the Region, three WHO fellows from Cyprus and Saudi Arabia were provided with training in various aspects of vector and biological control, and five national training courses were organized in Bahrain, Jordan, Saudi Arabia, Sudan and Tunisia. Through these training courses, 150 nationals including physicians, mid-level personnel and technical support staff from national disease vector/pest control programmes were trained.

Countries were provided with regular updates on new developments through technical support and provision of selected technical material published by the Regional Office and WHO headquarters. Consultancies to Bahrain, Cyprus, Djibouti, Jordan, Oman, Sudan and Republic of Yemen in covered such different technical fields such as the use of insecticide-impregnated bednets, biological control, monitoring of insecticide resistance, vector surveillance and rodent control.

Within the context of the regional initiative on the use of insecticide-impregnated bednets and other materials (IBMs), a subregional training course, supported by AGFUND, on environmental protection from disease vectors and use of IBMs was held in Aleppo, Syrian Arab Republic. Participants from Bahrain, Jordan, Lebanon, Libyan Arab Jamahiriya, Palestine and Syrian Arab Republic were trained in the methodology of IBMs.

Technical information and advice was provided to countries on a regular basis on insecticide resistance management; the majority of countries have now adopted the integrated vector control (IVC) approach. The WHO special test kits, standard solutions and insecticide test papers were provided to the countries on request. As a result insecticide resistance monitoring, especially in malaria vector mosquitos has improved considerably in the Region. The Regional Office conducted two workshops in the United Arab Emirates on insecticide susceptibility and resistance testing and monitoring; 43 nationals including scientists, physicians, field supervisors, public health officers and health inspectors were trained.

Regional Centre for Environmental Health Activities

The Regional Centre for Environmental Health Activities (CEHA) based in Amman, Jordan, was given the status of specialized centre for environmental health activities in the 1999 restructuring. In its seventh meeting, CEHA's Technical Advisory Committee expressed satisfaction with progress in 1998-1999 and the proposed plan of action for 2000-2001. CEHA further increased its efforts in 1999 to raise extrabudgetary funds. Nine new proposals were submitted to AGFUND, IDB, AFESD, the International Development Research Centre, DFID, the Kuwait Fund for Development, the European Community and other donor agencies for funding. More that 60% of 1998-1999 activities were funded from extrabudgetary resources, and more than 90% will be funded from such resources in 2000-2001.

The six special studies initiated in 1999 are due to be completed in 2000. Preparation for two epidemiological special studies on the health aspects of wastewater reuse, and two studies on identification of the optimum methods for removal of nematodes and Strongyloides larvae from the final effluent of wastewater treatment plants were completed and implementation of these studies will start by mid of 2000.

CEHA's role in promoting environmental health during emergencies involved missions to Afghanistan, Oman, Somalia and Syrian Arab Republic to solve urgent water contamination and wastewater treatment problems. Within the framework of the regional programme on monitoring environmental health conditions in the Region, technical support was provided to the Syrian Arab Republic and Tunisia with regard to establishing national environmental health profiles. The database on environmental health indicators being compiled at CEHA is growing. CEHA participated in the meeting of Arab experts on environmental indicators in April 1999 and in the first League of Arab States conference on environmental indicators in October 1999, advocating on both occasions for inclusion of the core environmental health indicators in the list of required environmental indicators of the League of Arab States.

CEHA continued its drive to promote water demand management and conservation as important components of integrated water resources management, advocating increased attention to demand management at the Fourth Gulf Water Conference in February 1999. CEHA held its third regional workshop on water demand management and conservation in April 1999 with the participation of 17 countries. A study of success stories in water conservation was commissioned in Bahrain, Cyprus and Tunisia to provide evidence of the importance of demand management and conservation and provide recommendations for successful water demand management programming. A source book on water conservation has been developed to provide planning tools and guidelines for best management practices. Awareness programmes regarding water conservation and sound handling of sanitation were launched during 1999. An awareness booklet entitled Enhancement of water and sanitation conservation and sound handling was tested in Jordan and the Syrian Arab Republic and the initial feedback was very promising. Syrian television used the package in a competition during Ramadan, while in Jordan it was published in a daily newspaper. It is now planned to carry out similar action in other countries.

In addition to its regular activities in production and dissemination of training and learning materials, national workshops on promotion of training, education and awareness (TEA) packages were held in Jordan, Oman, Saudi Arabia and Syrian Arab Republic, and four countries (Egypt, Morocco, Pakistan and Saudi Arabia) were selected to assess the TEA packages in Arabic, English and French, under a project co-funded by AGFUND. In collaboration with WHO headquarters and the Regional Office for Europe, CEHA reprinted and disseminated the addenda to the second edition of WHO's Guidelines for drinking-water quality in English. An environmental health training manual for school students was developed and finalized.

CEHA supported environmental health education through schools in Egypt, Saudi Arabia, United Arab Emirates and Republic of Yemen. Also, in the United Arab Emirates a healthy school workshop was carried out with clear focus on the environmental health dimension. A pilot project in three schools with different socioeconomic characteristics in Jordan, launched in 1998 as part of the regional healthy school programme and implemented in collaboration with the ministries of health and education, as well as some national nongovernmental organizations, ended in December 1999. A proposal to expand the programme to cover more schools in Jordan and to initiate pilot projects in other countries is under consideration.

Under the regional project launched in 1998 in collaboration with AGFUND on training relating to health and environment with special reference to mothers and children's health, four national courses were held in Lebanon, Morocco, Oman and Pakistan, environmental health materials were produced, and a regional workshop on the promotion and use of environmental health awareness materials with special focus on women and children was held in Amman, Jordan. Participants shared national experiences in the design of educational materials targetted at women and children and of the impact of awareness raising among women in improving environmental health conditions. Resources and other requirements for sustainable national public environmental health awareness and educational programmes were reviewed. In recognition of the importance of environmental health awareness among women in small and rural communities, CEHA in collaboration with the Regional Office and the Princess Basma Women's Resource Centre in Jordan, undertook an initiative involving the development of specific environmental health modules dealing with issues in small and rural communities, and training of women through national and local training courses.

The services of the Regional Environmental Health Information Network (CEHANET) now reach more than 4800 professionals and about 410 institutions in the Region. In 1999, CEHA distributed more than 5000 documents and responded to about 400 information inquiries. In order to promote information networking in the Region, CEHA worked to strengthen national information exchange and networking capacity, and to develop information processing systems and tools. Two modern environmental health documentation centres were completed in West Bank and Gaza. Two national training courses were held on modern information management and processing and both centres were supplied with core environmental health literature. These centres will be responsible for improving access to WHO information at the national level, as well as for networking among health and environment-related agencies. Support was also provided to the Ministry of Water and Irrigation of Jordan for the establishment of a modern water information centre. This centre will be a focal point for a regional water information network including Egypt, Lebanon, Palestine and Syrian Arab Republic. Similar support was provided to the Jordanian General Establishment for Environmental Protection.

Development and upgrade of CEHANET standard tools continued in order to keep up with modern information exchange and management procedures. A subject analysis handbook was developed and finalized in Arabic and will help health and environment information departments to handle and exchange information in a standard manner. Such tools are lacking in Arabic and this product is being requested by other international agencies to support their information activities and networks in the Region.