The Work of WHO in the Eastern Mediterranean
Region
Annual Report of the Regional Director
1 January - 31 December 1997
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The Work of WHO in the Eastern Mediterranean
Region |
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4.1 Reproductive, family and community health and
population issues 4.1 Reproductive, family and community health and population issues
Promotion of reproductive health and population issues The consultative process in working out the programmatic framework for this approach, which was initiated by the WHO headquarters’ programme on Family and Reproductive Health in 1995 through consultative meetings with interested parties, continued in 1997 with the full participation of the Regional Office with representatives from countries of the Region, which contributed their own experiences. In this regard an interagency technical consultation on safe motherhood was convened in Colombo, Sri Lanka, in October 1997, in which the Regional Office for the Eastern Mediterranean and representatives from Egypt, Jordan, Islamic Republic of Iran, Pakistan, Tunisia and Republic of Yemen dealt with the administrative issues concerned with the adoption of the reproductive health concept and concluded that safe motherhood was the most important objective of this strategy. This consultation not only sensitized programme managers in countries of the Region towards the importance of reproductive health care but also outlined the importance of safe motherhood as a high priority area for reproductive health care. The consultation also discussed successful approaches and strategies for reducing maternal and neonatal mortality and morbidity. During 1998, an intercountry consultation will be held on safe motherhood to assess progress in the Region in making motherhood safer in the 10 years since the 1987 Nairobi Declaration. Collaborating centres in reproductive health research in several countries, including Egypt, Islamic Republic of Iran, Pakistan, Sudan and Tunisia, continued to receive support from the WHO Special Programme of Research, Development and Research Training in Human Reproduction. Other reproductive health research projects are supported in Morocco and Saudi Arabia. An intercountry meeting on women’s needs and gender perspectives in reproductive health in the Eastern Mediterranean Region was held by the Regional Office in collaboration with the Special Programme. This meeting was primarily designed for national programme managers, researchers and nongovernmental organizations with research experience in various facets of reproductive health to develop a common ground for reproductive health research among all interested parties in the Region. The meeting was the first major exercise of this nature in the Region, and the Regional Office maintains close contact with the participants to monitor the progress of reproductive health research in the Region. As part of the demographic transition, commonly known as the "greying of nations" female life expectancy is increasing, but at the same time women have a higher level of morbidity than men, which to a large extent is because of their reproductive role. Recognizing the urgent need to review the quality of life of post-menopausal women and explore approaches to the reproductive health care of this segment of the population, the Regional Office held an intercountry workshop on post-menopausal reproductive morbidities, which focused on how to avoid the tragic implications of the greying of nations. National experts on gynaecology, gerontology and social science were invited from 12 countries to review the quality of life of post-menopausal women with special focus on their health status and socioeconomic conditions, and to outline a strategy that would respond to their specific health needs. Another important element of reproductive health care programmes that is being adopted by an increasing number of countries in the Region is screening and counselling services for the purpose of prevention of inborn errors of metabolism and hereditary disorders, such as thalassaemia and sickle cell anaemia, neural tube defects and glucose-6-phosphate-dehydrogenase deficiency, which are significant problems for children in several countries in the Region.
Reproductive health, with its main focus on maternal and neonatal
health, family planning and early detection and management of sexually
transmitted diseases, is a priority area for both WHO and UNFPA.
Collaboration with UNFPA in support of reproductive health care,
including family planning services, continued during 1997 in Djibouti,
Iraq, Jordan, Lebanon, Palestine, Somalia, Syrian Arab Republic and
Republic of Yemen. In 1997, the Regional Office continued to call for a holistic approach to child health and development and collaborated with countries of the Region to promote the fact that violation of children’s rights is an important cause of impairment of health and quality of life among children. Several countries in the Region have already made significant progress in providing better conditions for children’s health and development, through, for example establishing regulations to protect and promote child health and development, as in Egypt, and in providing quality care services for children, as in the United Arab Emirates. The
emphasis on the promotion, protection and support of breast-feeding
through child health programmes is continuing. In 1997, the Regional
Office intensified its collaborative activities with countries of the
Region to help them organize training programmes, develop and implement
national codes for regulating the marketing of breast-milk substitutes,
and strengthen child health programmes with this objective in mind.
Further support was extended to the WHO Collaborating Centre on Research
and Training in Breast-feeding in Teheran, Islamic Republic of Iran, to
strengthen its capabilities to support activities to promote
breast-feeding in the Region.
Collaboration with countries of the Region in reviewing the existing
adolescent health programmes and activities continued in 1997 with the
main objective of a better response to the special needs of the
adolescents in their societies. Technical support was provided to
countries to establish requirements for strengthening national
adolescent health programmes using the grid method approach developed by
WHO headquarters. This approach provides local health and social workers
with a methodology for analysing common problems of adolescence and
finding solutions. Several countries of the Region, including Egypt,
Jordan, Saudi Arabia, Tunisia and United Arab Emirates, have made
significant advances in the area of adolescent health through community
mobilization, health and social research and providing quality services. Progress in women’s empowerment has been achieved in most countries of the Region as a result of the effective policies and strategies adopted by the governments of these countries. National commissions on women’s health and development have been established in the majority of these countries. Greater focus is now placed on equality and gender issues and on raising public awareness in this area. with special interest and support from the highest level of leadership. The Regional Office continued to contribute to the work of the Global Commission on Women’s Health and the Task Force on Health and Development, and played an active role in projecting the specific health needs of women of the Region in the context of the Region’s prevailing religious values and sociocultural norms. In addition to extending technical support to countries of the Region on various aspects of women’s health and development, the Regional Office in 1997 assisted in the conduct of national meetings and workshops on priority areas to further strengthen national programmes and activities on women’s health and development. In
order to review socioeconomic and cultural factors affecting women’s
health in the Region, the Regional Office in collaboration with WHO
headquarters and UNFPA convened an intercountry meeting on women’s
health and their quality of life in October 1997. Experts on women’s
health, social scientists and researchers from several countries
participated in the meeting, in which major underlying determinants of
women’s health in the Region were identified to assist countries in
their efforts to develop and strengthen their national programmes and
activities to improve the quality of life of women during their entire
life span. The
Regional Office continued to support national efforts to increase
awareness of the needs of the elderly through the mass media, and to
advocate the needs of the elderly to the public, policy-makers,
religious leaders and nongovernmental organizations. In 1997 the
Regional Office also began to gather information from countries on the
existing support for the welfare of the elderly and the main areas of
achievement and constraint. The collected data are currently being
analysed in the Regional Office so that successful national experience
with issues relating to the health of the elderly can be disseminated
among countries of the Region. During 1997, as part of national efforts to develop and strengthen national programmes on occupational health and work safety, the Regional Office collaborated with some countries in the conduct of national situation analyses to obtain reliable information on mortality and morbidity patterns of workers of different categories and at organized and unorganized work sites in order to formulate appropriate national strategies which would respond to the local needs. In
order to assist countries of the Region in their efforts to introduce
occupational health services into their national primary health care
systems, the Regional Office held an intercountry consultation for
development of a training course for community health workers in
occupational health in 1997. The consultation outlined a training
framework that would enable community health workers to recognize most
common hazards in the workplace, create the know-how for controlling
them and use the support available to them for referral and medical
consultation. As a result, a model training manual is now being prepared
in the Regional Office and is expected to be available to countries of
the Region in 1998. During 1997 the Regional Office continued its collaboration with countries of the Region in reviving and strengthening school health services by promoting: collaboration between the health and education sectors; incorporation of measures for the promotion of health in school curricula; and the development and implementation of a health monitoring system and health education through design of appropriate school curricula and training of teachers and students to play active roles as agents of change.
4.2 Healthy behaviour and mental health In 1997, a regional consultation on mental health legislation in different law traditions including Islamic law was held in Kuwait in collaboration with the Islamic Organization for Medical Sciences. This consultation was attended by religious leaders, legal experts and mental health professionals from different countries of the Region. The proceedings and recommendations of this meeting are a possible basis for mental health legislation in Islamic countries. Another intercountry meeting was held in 1997 on mental health needs assessment. The report of this meeting would make a suitable guideline for a scientific assessment of mental health needs, perceived and otherwise, in the countries of the Region. This in turn, will increase the efficiency of national mental health programmes. In collaboration with the Nations for Mental Health programme, which functions under the Division of Mental Health and Substance Abuse at WHO headquarters, a major event for the promotion of mental health was held during the Forty-fourth Session of the Regional Committee in October 1997. The aim of this event was to bring the importance of mental health to the attention of ministers of health and other high-level health officials in the Region. A joint declaration was signed by the ministers of health and/or heads of the delegations from the countries of the Region. As a follow-up to this event, letters were sent to ministries of health, proposing to them a programme comprising 10 different activities for possible implementation in their national programmes. As well during 1997, two country-level demonstration projects were initiated in Egypt and the Republic of Yemen in collaboration with the Nations for Mental Health programme. Both projects aim to integrate mental health into the primary health care system by training general practitioners and health workers in two demonstration areas, one in Alexandria, Egypt, and the other in Matnaa, near Sana’a, Republic of Yemen. Two new
regional collaborating centres for mental health were designated: the
Fountain House in Lahore, Pakistan, which will be active mainly in the
area of psychiatric rehabilitation (pending government approval), and
the Teheran Psychiatric Institute, Teheran, Islamic Republic of Iran,
which will be active mainly in the area of integration of mental health
into the national primary health care system. The Regional Office participated in the UNIDCP Forum on Demand Reduction for the Middle East, held in Abu Dhabi, United Arab Emirates, in which Bahrain, Egypt, Islamic Republic of Iran, Jordan, Oman, Pakistan, Qatar, Saudi Arabia, Syria, United Arab Emirates, and the Republic of Yemen participated. The Regional Office was one of the main technical resources for this meeting. The Regional Office also actively participated in a meeting organized by the International Council on Alcohol and Drug Abuse (ICAA) held in Cairo. In this meeting, the Regional Office worked with the Islamic Organization for Medical Sciences in organizing a special symposium on substance abuse. In collaboration with the WHO programme of substance abuse, efforts are being made to hold a regional meeting for demand reduction in 1999. World No-Tobacco Day (31 May 1997) was celebrated widely throughout the Region. Several health ministries produced health education materials on the dangers of smoking in general and on the hazards of passive smoking in particular. The participation of nongovernmental organizations in the tobacco-or-health programmes further increased during 1997; they have been particularly active in producing health education material and in conducting workshops on the hazards of smoking. In
1997, tobacco-or-health medals were awarded to HE Dr Najeeb Sayeed
Ghanem, former Minister of Public Health, Republic of Yemen; Saudi
Sports Medicine Association, Riyadh, Saudi Arabia; Dr Shoaib Khan,
Medical Superintendent, Holy Family Hospital, Pakistan; Ministry of
Health, Iraq; Mr Ahmed Sultan, Governor of Damietta Governorate, Egypt;
Comité national olympique marocain, Morocco; and HE Dr Mohamed Eyad
Chatty, Minister of Health, Syrian Arab Republic. The Regional Office collaborated with 16 countries of the Region in the planning and implementation of 23 national workshops for health educators, teachers of primary schools, family physicians, scout leaders, media personnel and social workers. The results of the workshops showed that countries of the Eastern Mediterranean Region have been active in developing national health education programmes and have produced considerable amounts of health education materials of a high standard. In the field of human resources development, WHO fellowships in health education and the school health curriculum were awarded to fellows from eight countries of the Region. As well, the Regional Adviser for health education participated in teaching health education to students of community health and in national training workshops for health education. During 1997, the Regional Office continued its close collaboration with international organizations interested in health education, particularly UNICEF, UNESCO and ISESCO. With the collaboration of UNICEF, UNESCO and ISESCO, the Regional Office conducted an intercountry meeting on methods of implementing the prototype health education curriculum for adult education. The Regional Office also collaborated with ISESCO in the conduct of two regional workshops on health education for directors of adult education. WHO collaborated with the Scout Movement for the Arab Region in preparing a health education guide for scout leaders and prepared three films, on hazards of tobacco, drugs and sexually transmitted diseases. It is satisfying to note that surveys have indicated that the impact of health education programmes on people’s knowledge and behaviour is highly positive. The Health Education and Noncommunicable Diseases units conducted an intercountry workshop in Morocco in May 1997 on methods and techniques of production of health education material for noncommunicable diseases. A guide was developed and distributed to all health education focal points in countries of the Region. Implementation of the prototype action-oriented school health curriculum was actively pursued in 17 countries in collaboration with the Regional Office. WHO support included technical and financial support for national workshops and support for translation of the material into national languages, particularly the translation into Urdu, Dari and Pushtu of the full series of eight volumes of the prototype action-oriented school health curriculum for primary schools.
Fellowships were awarded to school curriculum development personnel to
facilitate visits to active curriculum development programmes and allow
exchange of experience with the people concerned in the ministries of
education. The two national workshops on media and health were held in Bahrain and Morocco with participation from national radio, television, newspapers and magazines. The main purpose of such workshops is to get the media more actively involved in promoting healthy lifestyles. They were organized with the full cooperation of the ministries of health in both countries. Such workshops, which are now a regular activity of the Public Information Unit, also aim to improve mutual understanding and cooperation at the national level between the media and ministries of health. So far, national media workshops have been organized in six countries of the Region. Further workshops are being planned in other countries. The regular output of the Public Information unit has been maintained. Forty press releases were issued in Arabic and English during the year. These are always sent by fax to ensure timely delivery. Press kits were also issued on emerging infectious diseases, the theme of World Health Day (7 April 1997), and multisectoral cooperation in tobacco control, the theme of World No-Tobacco Day (31 May 1997). The unit also arranged media coverage during the Forty-fourth Session of the Regional Committee in the Islamic Republic of Iran, as well as coverage of major events in Egypt, at the Regional Office for the Eastern Mediterranean, and in other countries. The unit followed the practice of the past few years and organized a drawing and painting competition for schoolchildren aged 8 to 18 years who were asked to portray the theme of World Health Day 1997 (emerging infectious diseases). More than 2500 entries were received from the countries of the Region. Prizes were given to winners in five age groups. In some cases, this took place in a special ceremony attended by senior national officials. This competition aims to expose young people to basic health concepts and has now been established as an annual event. Steady progress has been made in regionalizing the unit’s video output. The two videos prepared for World Health Day and World No-Tobacco Day were regional products with input from headquarters, particularly in relation to Ebola haemorrhagic fever, tuberculosis and other emerging infectious diseases. Filming was carried out in several countries of the Region, including Egypt and Pakistan. Furthermore, the Regional Director’s messages on both occasions were produced on video and sent to all countries of the Region for showing on television and other uses. Cooperation with nongovernmental organizations has improved, particularly with the Scout Movement. The unit cooperated with the Arab Scout Movement in the production of three video films targeted at young people. The themes tackled in these videos were drug abuse, sexually transmitted diseases and violence.
Contacts with national media were maintained in 1997, ensuring publicity
for significant WHO events. Bahrain and the United Arab Emirates have initiated separate programmes for the promotion of healthy lifestyles, but the activities related to identifying means of intersectoral cooperation to promote health-enhancing lifestyles and decrease health-damaging behaviour were rescheduled to be implemented in 1998. During his visit to Bahrain in 1997, the Regional Adviser discussed methods of evaluation of the national programme. A
regional consultation on policies and strategies to promote healthy
behaviour and lifestyles was held in 1997 to assess national programmes
of promotion of healthy lifestyles; to identify needs and to establish a
process to develop appropriate policies and strategies. Consultancies were provided to six countries during 1997. WHO consultants collaborated with national authorities in conducting a situation analysis for all types of injury and injury health impact assessment. They collaborated in the development of epidemiological knowledge on injuries and relevant information systems and advised on the formulation of national safety promotion policies and strategies. During these consultancies the establishment of information centres for data collection related to different types of injury and accident and the development of preventive and safety tools as a new approaches to improve safety were given special attention. The consultants also helped in the conduct of national workshops and training courses on strategies for accident prevention and the role of a multisectoral approach for implementation of programmes that are community-oriented, particularly at district level, in line with the philosophy of primary health care. Two research grants were provided to address the magnitude of accidents and trauma in schoolchildren and their impact. WHO fellowships in areas of safety promotion were awarded to fellows from Egypt, Lebanon and Syrian Arab Republic with emphasis on capacity-building of professionals in safety promotion at country and regional levels. The safety promotion programme in Afghanistan received technical and financial support to develop and produce educational materials on safety promotion for the use of public and health personnel. The
Regional Adviser for healthy lifestyles promotion visited Bahrain,
Jordan, Lebanon, Pakistan and Syrian Arab Republic to evaluate the
safety promotion programme. The Regional Adviser also participated
actively in the third International Symposium on Emergency Trauma, which
was held in Qatar in 1997. In the United Arab Emirates, a consultant assisted nationals in the formulation of a national system for oral health care and finalized with them the formulation of a national systematic oral health care master plan with special emphasis on establishing supportive curative care for children aged 4–9 years, preparing a plan of action for the national team on oral health programme implementation and organizing a training course on clinical preventive care for national dentists from selected dental centres. In the Islamic Republic of Iran, a consultant conducted a learner-centred workshop on community-based dental curricula and assisted nationals in preparing an oral health manual for medical students on preventive measures. Forty-six (46) national workshops on preventive oral health measures for dentists and paramedics were held with WHO collaboration in 13 countries of the Region. These workshops produced educational materials on preventive measures in oral health. For Afghanistan and Iraq, manuals on oral health for oral health personnel were prepared and printed with WHO support. Also with WHO support, the oral health programme of the Islamic Republic of Iran produced a video film on preventive measures in oral health. WHO fellowships in oral health were awarded to fellows from 11 countries with the aim of developing human resources and capacity building of oral health personnel at country and regional level. In addition to consultants’ visits, the Regional Adviser visited Bahrain, Lebanon, Pakistan, Qatar and Syrian Arab Republic to evaluate the national oral health programmes. He also visited the Republic of Yemen to help nationals at the Faculty of Medicine, University of Sana’a, to establish the proposed school of dentistry. The WHO collaborating centre on training and research in oral health (the Regional Demonstration, Training and Research Centre for Oral Health) in Damascus, Syrian Arab Republic, continued to play an important role, offering several training courses in the planning and management of oral health programmes. With the participation of the Regional Office, the centre designed courses for nationals from Cyprus, Sudan and Syrian Arab Republic. In addition, staff participated in the preparation of oral health educational materials such as posters, pamphlets, handouts and slides. The centre has produced a video film on practical and clinical application of fissure sealant as a preventive measure in oral health. The centre’s educational materials are now used in many oral health programmes in the Region, including those in Oman, Qatar and Sudan. In
order to strengthen the relationship between WHO and nongovernmental
organizations, the Faculty of Dentistry of the University of Milan,
Italy, provided support to the regional oral health programme. Under
this programme, training of oral health personnel on atraumatic
restorative treatment (ART), as a preventive oral health measure, was
organized in Gaza and the West Bank. Further collaboration in this
regard is expected in 1998–99. Collaborative activities were mainly related to the development of community-based rehabilitation (CBR) programmes and in this regard technical support was provided to Afghanistan, Bahrain, Egypt, Islamic Republic of Iran, Iraq, Pakistan and Saudi Arabia. This support was for further development of CBR programmes and orthotics and prosthetics technology. Training and provision of publications continued throughout the year, as did collaboration with other UN agencies and nongovernmental organizations in the area of rehabilitation. 4.3 Nutrition, food security and safety
Promotion of healthy nutrition In the area of feeding of infants and young children, efforts to protect, promote and support breast-feeding continued. Bahrain, Cyprus, Djibouti, Egypt, Iraq, Kuwait, United Arab Emirates and Republic of Yemen conducted training courses on breast-feeding counselling, while a new course for policy-makers and administrators on breast-feeding and its importance was conducted in Kuwait. In the area of nutrition emergency preparedness, the Field guide for rapid assessment of nutritional status in emergencies, which was already available in English and Arabic, has now been translated also into French. All 16 countries that had previously identified iodine deficiency diseases (IDD) as a public health problem are now iodizing their salt. Universal salt iodization is a reality now in most of these countries, while even countries which have very mild IDD have also opted for iodized salt, be it imported or locally produced. A survey of urinary iodine excretion in schoolchildren was carried out in the Islamic Republic of Iran to monitor the impact of the universal salt iodization programme, which has been going on for several years. The survey demonstrated that IDD has been eliminated in this country. To ensure continued vigilance and to emphasize the importance of monitoring it is anticipated that a workshop will be held in 1998 on the methods of monitoring the impact of iodization of salt. As well, the booklet Iodine deficiency: what it is and how to prevent it has been translated into Arabic and reprinted in English. The pamphlet is widely used for advocacy and mobilization. Efforts to address iron deficiency continued, which affects about half of the women and children in the Region. Recent surveys carried out in countries of the Region time and again underscore the fact that this deficiency is still far from being controlled. The deleterious effects of iron deficiency on learning ability and work performance warrant urgent action to protect future generations of children. Since the WHO/UNICEF/Micronutrient Initiative/Programme against Micro nutrient Malnutrition strategy development workshop, held in Muscat, Oman, in 1996, action has been taken in many countries. Flour is now fortified with iron and folate in Kuwait, Oman and Saudi Arabia, while Bahrain and others are studying the feasibility of this intervention. Results of the iron fortification trial in Isfahan, Islamic Republic of Iran, will assist the Ministry of Health and Medical Education to take further action on iron deficiency control. At a recent meeting of flour millers from all over Africa and the Middle East, held in Bahrain, the issue of flour fortification was raised and information provided on the outcome of the 1996 Oman workshop. The WHO/UNICEF document entitled Guidelines for the control of iron deficiency in countries of the Eastern Mediterranean, Middle East and North Africa has been translated into Arabic and widely distributed. Vitamin A deficiency is still a significant public health problem in several countries of the Region, notably Djibouti, Iraq, Pakistan, Somalia and Republic of Yemen. Recently conducted studies in Egypt, Morocco and Oman have shown that subclinical vitamin A deficiency, with its inherent risk of increased mortality, is prevalent. The International Vitamin A Consultative Group (IVACG) meeting was held this time in Cairo, Egypt, and many countries from the Region participated actively and presented new information on their activities in the fields of vitamin A deficiency control. On the basis of a very interesting study of the suitability of breast-milk vitamin A for programme monitoring, Oman has decided to give high-dose vitamin A supplements to pregnant women within six weeks of delivery to protect them and their young infants. Control activities aiming at improving the vitamin A status of young children are currently ongoing in many countries, while vitamin A capsules will routinely be distributed as part of national immunization days. A workshop on micronutrient malnutrition and its control in emergencies was held in Nairobi, Kenya, for health workers and field staff from UN agencies and nongovernmental organizations working in Somalia. The Fourth Regional Training Course in Nutrition hosted by the Nutrition Institute in Cairo, Egypt (WHO Collaborating Centre for Research and Training in Nutrition), was successfully completed, and participant selection for the fifth course is well under way. This very successful course has trained participants from Afghanistan, Bahrain, Djibouti, Egypt, Kuwait, Oman, Saudi Arabia, Sudan, Pakistan and Palestine, most of whom now have responsible jobs in nutrition promotion in their countries. Decentralization of the course to country level will soon start in two countries, using flexible modules for nutrition training, which were produced by the Regional Office. The modules contain a skills-based, objective-oriented course curriculum, with extensive guides for facilitators and course participants, to foster participatory learning. The food and dietary analysis software (EMRO version), which incorporates food composition tables from countries of the Region and which was developed by the Danish Catering Centre, WHO Collaborating Centre for Nutrition, in Copenhagen, Denmark, has been used in a number of countries and will be developed further based on the initial experiences. A training workshop was held in the Islamic Republic of Iran, to train nationals on the use of computer programs like Epi-info and Dankost for conducting dietary intake surveys and analysing nutritional status. At the regional level, a further training course using Dankost (EMRO version) and the new training modules will take place in 1998. The importance of valid dietary intake data and information on consumption patterns was again brought out by a conference on nutrition and chronic diseases held jointly by the Bahraini Ministry of Health and WHO in late 1997.
Promotion of food safety The Hazard Analysis Critical Control Point (HACCP) system as a preventive approach to the control of food processing has again received the attention it deserves. An AGFUND/CEHA workshop on food safety held in Sharjah, United Arab Emirates, in October 1997, pointed out that HACCP is an essential prerequisite for food safety and must be a component of any quality control system. International trade in food commodities relies more and more on the presence of an effective HACCP plan. Egypt recently issued a presidential decree making HACCP mandatory in food processing. HACCP training courses have been carried out in Cyprus, Egypt, Iraq, Islamic Republic of Iran, Jordan, Libyan Arab Jamahiriya, Morocco and Tunisia. In several of these countries the national capacity for HACCP has been strengthened through fellowships. An intercountry workshop on the role of HACCP in national food control systems will be held in April 1998 in Tunisia. Many countries in the Region have become effective participants in the work of Codex Alimentarius and other important aspects of food safety. A recent meeting of the Codex Committee for Asia (CCASIA), held in Thailand, was for the first time also attended by countries from the Region (Kuwait, Qatar and United Arab Emirates). Regional guidelines for strengthening the role of national Codex focal points and the development of national Codex coordinating committees, developed by CCASIA have been provided to all countries of the Region to assist them in more active and coordinated participation in the work of Codex. This is even more important given the existence now of the World Trade Organization (WTO), as Codex is considered the "gold standard" for WTO arbitration. A well functioning food control laboratory is essential for an effective food control system. While the burden of multiple and massive end-product testing is reduced when more and more food-processing is done using the HACCP approach, new challenges face the food control laboratory. The Regional Office has assisted Cyprus, Egypt, Iraq, Jordan, Lebanon and Sudan in strengthening their laboratories, while Iraq, Jordan and Tunisia have undertaken action in the area of quality control. The Regional Office continued to regularly inform countries of the Region of important incidents and emerging problems related to food safety. A regional conference will be held in October 1998 to brief food control managers in countries of the Region on newly emerging food-borne pathogens and their control. Management of water supply and sanitation In spite of formidable barriers caused by water scarcity and high costs, many countries in the Region have devoted resources and energy to ensuring that people have adequate water supply, and have made impressive achievements. In many countries however, groundwater is being mined. The most serious cases of ground water depletion are in Gaza in Palestine, in the Sana’a basin in the Republic of Yemen and to a certain extent in Djibouti. Figure 4.1 shows the water supply coverage for different groups of countries.
While efforts in a number of countries have resulted in increasing water supply coverage, the civil strife in Afghanistan and Somalia is a major barrier to the expansion of the programmes in these countries. Djibouti, Sudan and Republic of Yemen do not receive the level of support from the external donors that they need. The extent of donor support in these countries is much lower than in the past. The level of sanitation coverage in urban areas in many countries is, by and large, satisfactory. However, low sanitation coverage in the rural areas continues to be an impediment to health development. The high cost is a constraint for providing extensive sewerage systems to urban centres. The majority of countries do not have a clearly defined sanitation strategy. Sanitation must be given the priority it deserves in infrastructure development. Figure 4.2 shows the status of sanitation in countries of the Region.
The Regional Office has promoted and mobilized sanitation projects in the countries with low sanitation coverage. The global WHO sanitation strategy that was originally proposed by the Regional Office was further developed and has been accepted by the Executive Board. In view of the Region’s water scarcity, the Regional Office has paid special attention to wastewater reuse. As part of the activities of the Inter-Agency Task Force (IATF) on land and water resources, WHO and FAO have been collaborating on wastewater reuse. The two agencies along with other members of IATF organized and held an expert consultation on the use of low quality water for sustainable agriculture in December 1997 at the WHO Regional Centre for Environmental Health Activities (CEHA) in Jordan. A total of 36 people representing seven international and regional organizations, as well as resource persons and observers participated in the consultation. The meeting made a number of important recommendations, especially on development of a Wastewater users manual at the farm level. The water supply and sanitation programme in Afghanistan continued its remarkable success in providing more people with water and sanitation facilities. The work for rehabilitation and expansion of water supply systems in more than 15 cities and towns including Ghazni, Zaranj, Charikar, Maydan Shahr, Mehtar Lam, Konduz, Jalalabad, Kandahar and Faizabad forged ahead. Activities for rehabilitation of the systems in Bamian and Nimruz have been initiated, and WHO is collaborating with UNICEF for upgrading of the system in Lashkar Gah. WHO-assisted water supply and sanitation activities are enjoying large-scale support from UNDP, UNHCR, UNFPA, UNOCHA, UNICEF, Qatar funds, Kuwait funds and the Red Crescent Society. Held in cooperation with CEHA, a national seminar on drinking-water quality in Saudi Arabia brought together a large number of participants representing many interested parties in the country. It reviewed the tremendous progress made in the country to ensure the supply of drinking-water and made recommendations calling in particular for the establishment of a national commission on drinking-water safety and for the creation of a Saudi water society. During 1997, the Regional Office collaborated with a number of countries providing technical support in the form of consultants and nationally recruited experts in priority water supply and sanitation. Fellowships were awarded to national staff in eight countries, and funds and technical support were provided by WHO for national seminars and training activities in six countries, including seminars on drinking-water quality. Supplies and equipment were purchased for monitoring and other purposes for nine countries. CEHA organized two training courses on hygiene education and social behaviour in Afghanistan and Somalia to develop the capacity of sanitation inspectors. CEHA also promoted the use of low-cost technologies. Twenty video programmes and 20 booklets were prepared in Arabic to assist engineers, decision-makers, and community leaders to select appropriate technologies. This package won a special award from the council of Arab ministers responsible for the environment of the League of Arab States. In addition to this, CEHA’s documents Guidelines on sanitation for small communities and Guidelines on technologies for water supply systems in small communities were translated into Arabic and disseminated to focal points in all the countries of the Region. As a
follow-up to recommendations made by countries of the Region, CEHA
drafted a regional water conservation strategy, which proposes a
comprehensive approach to dealing with this issue by including the
domestic, agricultural and industrial sectors. In the related areas, in
collaboration with the International Atomic Energy Agency, CEHA held a
regional workshop on integration of isotope studies into effective water
resources management practices. The healthy cities programme in the Region is expanding rapidly, and currently more than 40 cities are part of the regional healthy cities network. However, some of the ongoing healthy city projects do not have clear objectives and specific activities. Also, not all projects have adopted truly participatory and community-based approaches. There is also a need to collect baseline data, develop information systems, establish networking (from local to global levels) and mobilize resources. To review the progress of the activities in the Region and address the above issues, the regional meeting of healthy cities coordinators was held in September 1997 in Muscat, Oman. A total of 35 people representing 14 countries, UNDP/LIFE, CEDARE and UNICEF along with WHO staff, consultants and resource persons participated in the meeting. The meeting recommended specific steps for strengthening the programme in the Region. To assist in resource mobilization, WHO has prepared a number of project proposals for donor funding. In this regard, more efforts are needed by cities and national authorities to seek support from the international donors as well as to mobilize the internal resources. The healthy villages programme offers a very good prospect for improving environmental health in the rural areas. A regional consultation is planned for June 1998. Healthy villages programmes and projects are ongoing in Afghanistan, Egypt, Islamic Republic of Iran, Oman, Syrian Arab Republic and Republic of Yemen. The purpose of this Consultation will be to review and discuss the required technical guidelines for healthy villages programme and develop annotated formats for the priority guidelines. There are several successful healthy cities projects in the Region. In Afghanistan a healthy city project is operational in Jalalabad. This project is building low-cost latrines, improving drainage and aiming to upgrade the overall environmental health conditions in the city. Also, the healthy village project in Karte Moalemin in Kandahar is progressing well. A healthy school programme for a girls’ school in Kandahar has been initiated. This programme has created considerable interest among the local and international communities. In Egypt, the healthy city and woman’s development project in Alexandria has made real headway and has been instrumental in advancing the empowerment of women at the local level. This project is a collaborative activity between the local authorities, Plan International and the Regional Office. The activities of the project have raised women’s awareness of health and environmental matters and resulted in the improvement of environmental sanitation. The approach of the project is being adopted by other communities in Cairo and has evoked interest in other countries. Tunisia, which has been a pioneer in healthy cities activities, is implementing projects in Ariana, Ben Arous, Bizerte, Gabès, Hammam Sousse and le Bardo. In the Islamic Republic of Iran, many cities have initiated healthy cities projects. In Cyprus WHO has provided support for healthy cities activities in five municipalities. In Oman the healthy wilayat project in Wadi Ma’awil is progressing well. The healthy cities projects sponsored by WHO/UNDP/LIFE are progressing well in Fayoum, Egypt, and Quetta, Pakistan. In other activities, WHO consultants advised and assisted Djibouti, Pakistan, Oman and Qatar in connection with strengthening of healthy cities projects, management of health-care waste and sanitary inspection of housing units. Support was also provided for fellowships, training activities and national meetings in three countries. The AGFUND-assisted intercountry healthy village project is assisting the Arab countries. Also, ISESCO is providing support for healthy city projects in Fayoum, Egypt, Hammam Sousse, Tunisia, and Meknès, Morocco. CEHA organized a multinational workshop for Egypt, Sudan and Republic of Yemen. Furthermore, CEHA initiated an environmental healthy schools project in Jordan, which will be replicated in Egypt in 1998. The healthy cities projects in Morocco and Jordan require more support and attention. Lebanon and Gaza in Palestine have expressed interest in starting healthy city activities.
A ministerial conference on health, environment and development in the Eastern Mediterranean Region was held in Damascus, Syrian Arab Republic, in December 1997, with participation of ministers of health and environment or their representatives from 19 countries of the Region. The conference reviewed the countries’ situation and the progress made by the Regional Office in implementing the Beirut Declaration on action for a healthy environment, which was adopted by the Second Conference on Health, Environment and Development held in Beirut, Lebanon, in 1995. After
considering the Regional Plan of Action for Health and Environment
the Third Evaluation of the Strategy of Health for All by the Year 2000 and the situation in the countries as presented, the Conference concluded that there were several issues of paramount importance which should guide all future work on health and environment within the Eastern Mediterranean Region.
The ministerial conference also agreed on a series of recommendations aimed at countries of the Region, the Regional Office and the international community, among which was the following recommendation on plans of action for health and environment: "All plans of action [for health and environment] should be completed by end 1999 as agreed previously. Care should be taken that the plans are developed with full intersectoral participation and are implementable within the expected national and international resources. Once completed, these plans should be integrated within the sectoral (energy, agriculture, industry, health, etc.) plans, which jointly constitute the national plan for sustainable development". Concerning the Investment plan for health and environment in the Eastern Mediterranean Region, the approach included in the Plan of Action for Health and Environment in the Eastern Mediterranean Region was endorsed by the ministerial conference; consequently, attention will be given to establishing a small working group composed of health and financial planners to begin developing methodologies. In addition, a donor advocacy meeting involving regional banks, oil companies, multilateral and multinational funds should be convened with the purpose of obtaining backing for preparation and implementation of the plan. While the ministerial conference stressed the need for environmental health legislation to act as an umbrella for proper coordination and direction of various issues/activities related to health and environment, it recognized that there was no single model environmental health legislation applicable to the situations of every country in the Region. Within the joint UNDP/Capacity 21 and WHO country-based initiative for incorporating health and environment considerations into planning for sustainable development, the Regional Office extended technical support to several countries. WHO supported a national conference in the Islamic Republic of Iran to discuss amend and adopt a national plan of action. In Morocco WHO supported the Ministry of Environment through the Ministry of Public Health to introduce health considerations into the country’s national environmental action plan, which is itself part of the national planning process for sustainable development. WHO supported national workshops held in Egypt and Tunisia to discuss, amend and adopt national strategies and plans of action for health and environment, and in Sudan to examine the environmental health situation in the country and recommend application of the national strategy on health and environment. In Oman a national workshop on health and environment in sustainable development was organized to discuss the elements to be included in the national strategy for health and environment. Cooperation with the Arab League is continuing, particularly regarding the environmental impact of industrial activity and air quality guidelines. Working relations are ongoing with many other organizations, such as UNEP and ROPME. Environmental health impact assessment (EHIA) should be an integral part of all new development activities to ensure that such developments (industrial, agricultural, water, urbanization, etc.) minimize potential adverse effects on health and environment. While the use of EHIA has been accepted in a few countries, such practices are not yet common in many countries. Therefore, WHO, the Regional Office and CEHA continued promoting EHIA through development of a regional set of guidelines on EHIA of development projects in collaboration with the Liverpool School of Tropical Medicine. This was done through a CEHA regional workshop for countries of the Gulf Cooperation Council, and a series of national workshops and seminars in Egypt, Islamic Republic of Iran, Kuwait, Oman and Pakistan. Further follow-up activities were implemented in Egypt to help in the development of national guidelines. Other activities at country level include support for the creation of an environmental unit within the Federal Ministry of Health in Pakistan and to the Libyan Arab Jamahiriya to outline a plan for environmental health emergencies. Preparation of national standards for the examination of air quality was supported in Egypt. Training activities in matters of environment health assessment and planning, environment epidemiology, pollution monitoring and control, urban air quality and environmental health information were supported in Egypt, Islamic Republic of Iran, Iraq, Kuwait, Libyan Arab Jamahiriya, Morocco, Pakistan, Palestine, Syrian Arab Republic, Tunisia and Republic of Yemen.
Equipment and supplies were provided to various environmental health
monitoring centres in Egypt, Djibouti, Iraq, Jordan, Libyan Arab
Jamahiriya, Oman, Sudan, Tunisia and Republic of Yemen. At country level the awareness of the need for safe management of chemicals is improving but still a number of constraints exist, such as lack of coordination, lack of legislative frameworks and law enforcement to deal with hazardous chemicals, scarcity of trained personnel and good quality chemical analysis facilities, lack of awareness about occupational and other chemical exposure, and poor referral systems for chemical accidents and emergencies. Many countries have not yet established their national chemical safety programmes. However, the regional chemical safety programme provided technical support to countries of the Region to successfully deal with some of these constraints. The basis of regional policy continued to follow the recommendations of World Health Assembly resolution WHA45.32 and the recent Fiftieth World Health Assembly resolution WHA50.13 on the promotion of chemical safety, with special emphasis on prevention and safe management of persistent organic pollutants (POPs) and the reduction of reliance on chemical pesticides through the development of alternative methods for disease vector control One of the most important requirements for safe management of chemicals at country level is the availability of updated and comprehensive information on chemicals of all kinds, especially hazardous ones. At the same time the availability of multidisciplinary and multisectoral coordination is essential for all concerned in a country to ensure a programme’s sustainability. In order to produce information on hazardous chemicals at country level and ensure coordination of all the stakeholders it was felt essential to start the process of preparation of national chemical safety profiles (NCSP). A regional initiative for this purpose was launched in 1996. During 1997, countries were further supported through provision of summary guidelines and detailed WHO documents on this subject. The process of profile preparation has already been initiated in some countries. During 1997 national programmes for chemical safety were supported through the provision of technical support. Egypt, Iraq, Morocco, Oman and Pakistan were advised on ways of strengthening their chemical safety programmes, especially in preparation of NCSPs, preparation of inventories of hazardous chemicals, establishment of national registries of chemicals and strengthening of legislative control for the safe management of chemicals. The availability of trained managerial and technical human resources and the support of well informed and motivated higher level decision-makers is essential for sustainable development of national programmes. The regional chemical safety programme in collaboration with IPCS/Geneva conducted a one-day advocacy/ briefing meeting for high-level decision-makers and a five-day training course for technical managers in Pakistan. Thirty-five nationals were educated on various key elements of safe management of chemicals. In view of the potentially serious health and environmental hazards from increasing use of chemical pesticides, in agriculture and public health, a regional workshop on monitoring cholinesterase activity in humans was organized in October 1997 in Islamabad, Pakistan, in which 13 participants and nine observers from 10 countries of the Region were trained on techniques and methodology of cholinesterase monitoring. Safe use of pesticides, especially in developing countries, depends mainly on training of technical staff who deal with pesticides; education and creation of awareness in the community; and strengthening of national legislation and institutions such as poison information and control centres. During 1997, as in the preceding four biennia, the Regional Office continued to support national efforts on safe and judicious use of pesticides, through the distribution of an Arabic version of the manual for a multi-level course on the safe use of pesticides and on the diagnosis and treatment of pesticide poisoning. The regional drive to train trainers on safe use of pesticides continued. Technical support was provided to Iraq, where a WHO consultant supported the country in conducting a national workshop on safe use of pesticides, in which 30 trainers were trained. CEHA
also promoted chemical safety, in close collaboration with the
International Programme on Chemical Safety. Activities were targeted at
improving the access to chemical safety information, promoting the safe
use of chemicals and dealing with chemical emergencies. A regional
training workshop on chemical safety information was organized in which
participants from 10 countries were trained. Another regional workshop
was organized on collection of harmonized case data, INTOX and
management of toxic exposure. The Regional Office continued to give top priority to strengthening the capabilities of technical staff and to the transfer of appropriate and innovative techniques in various fields of vector biology and control. Collaboration with a number of universities and institutes within and outside the Region was continued, whereby six WHO fellows from Islamic Republic of Iran, Saudi Arabia and Syrian Arab Republic were provided with training in various fields of vector control. National training courses supported by the Regional Office were organized in Afghanistan, Egypt, Islamic Republic of Iran, Libya, Pakistan, Sudan and United Arab Emirates for mid-level and technical support staff from various national disease vector control programmes. The regional initiative on the use of insecticide-impregnated bednets, which was launched in 1994, continued. This innovative technique for the control of vectors of malaria, leishmaniasis as well as other insect vectors/pests of public health significance, which in 1993 was being tested on a small scale by only a few countries, is being tested on a large scale with field trials in Afghanistan, Egypt, Islamic Republic of Iran, Morocco, Palestine, Pakistan, Sudan, Somalia and Republic of Yemen. Countries continued to strengthen their integrated vector control (IVC) programmes, as a result of continued regional initiatives on IVC, highlighted by a regional workshop on IVC. By 1997 at least 10 countries had adopted an IVC approach to disease vector control. Countries of the Region were also encouraged to incorporate necessary safeguards against vector breeding in water resource development projects. To enable the national VBC programmes to deal with the problem of insecticide-resistance on scientific grounds and for appropriate planning of future pesticide application, the Regional Office continued supporting countries of the Region in insecticide susceptibility/resistance monitoring. The supply of WHO special test kits, standard solutions and insecticide test papers, and WHO guidelines on test procedures for mosquitos, sandflies, houseflies and other insects of public health significance were provided to countries of the Region. A regional workshop on pesticide resistance monitoring was organized in Pakistan. Thirteen participants from 10 countries were trained on pesticide resistance mechanisms in insects and other pests, the techniques and methods for measuring and monitoring resistance in insect vectors of diseases with special emphasis on anopheline malaria vectors. The Regional Office VBC programme continued to analyse the data on insecticide resistance received from countries, especially in the case of malaria vector mosquitos; feedback on the basis of analysis carried out was sent to country programmes to improve resistance management of vectors/pests.
Collaboration with the WHO headquarters Panel of Experts on
Environmental Management for Vector Control (PEEM) continued. Technical
material produced by PEEM was disseminated. Water supply and sanitation issues are still of high priority in the Eastern Mediterranean Region, as highlighted in the two conferences of ministers of health and environment in the Eastern Mediterranean Region held in 1995 and in 1997. Almost half of CEHA activities which were implemented during 1997 focused on these priority issues, while the rest were distributed among other issues such as environmental health impact assessment, water resources management, health care waste management, chemical safety, food safety and environmental health education and awareness. Environmental information and education received special attention in 1997. Several activities were implemented including production of documents and audiovisual materials for training purposes and introducing environmental health curricula into formal education in some of the countries of the Region. 1997 also saw fruitful collaboration with other organizations with similar interests, such as the Centre for Environment and Development in the Arab Region and Europe (CEDARE), UNEP Regional Office for West Asia, IAEA, FAO Near East Regional Office and IPCS, and with regional and international donor agencies such as AGFUND the Islamic Development Bank (IDB) and the Arab Fund for Social and Economic Development (AFSED). These collaborative efforts were essential to address the reduction in available resources, to minimize duplication of activities, and to optimize utilization of the available resources which are generally decreasing. In collaboration with WHO headquarters, CEHA reprinted and disseminated the second edition of the WHO drinking-water quality guidelines, volume 2, to focal points in all the countries of the Region. By reprinting at low cost, CEHA managed to overcome the high cost of this information barrier. CEHA collaborated also with Global Environment Monitoring System/Water (GEMS/Water) in Arabicization, printing and dissemination of the GEMS/water operational guide, which will help GEMS focal points to systematize water quality monitoring. Water disinfection pamphlets in Arabic and English were also disseminated. Funds were received from AGFUND to start implementing a new project, "Control of drinking-water quality and women’s role in sanitation". All necessary administrative and technical requirements have been completed, and the project is ready for implementation in early 1998. This project will focus mainly on supporting drinking-water monitoring systems in 12 countries. Periodic country level assessments of status and trends in environmental health situation are crucial for raising public awareness, obtaining political support and for decision-making. Unfortunately, this is still lacking in most of the countries of the Region. CEHA started to give more attention to this issue. Software was created to assist countries of the Region in collection and management of environmental health indicators. AGFUND agreed to sponsor two regional projects on supporting information management systems and public awareness. Activities under those two projects started in 1997. Food safety is a major environmental health issue in the Region for local consumers as well as for import and export. Most of CEHA’s activities in 1997 were done under the aegis of the AGFUND project " Support for environmental protection for health and development". Major activities were implemented in 1997 in close collaboration with the Regional Office nutrition and food safety programme, including an intercountry workshop on food safety for Member States of the Gulf Cooperation Council, and national training courses and workshops in eight countries. These courses were targeting promotion of the HACCP technique, as well as training of environmental health inspectors dealing with food safety issues. A special study was completed on lead poisoning in Qatar in collaboration with the Ministry of Public Health. The results of this study will be disseminated to all countries in the Region. The provision of technical information, the development of information systems and the use of this information must be part of any environmental health programme. In the Region, lack of access to reliable and timely information is still hindering the promotion of environmental health activities. CEHA, through its Regional Environmental Health Information Network (CEHANET), is trying to achieve two major goals: to maintain and strengthen its information exchange capacity; and to promote information networking at regional and national levels. To achieve the first goal, CEHA’s documentation unit was strengthened and equipped with state-of-the-art hardware and software needed to provide its services to countries of the Region. The CEHANET services now reach more than 4400 professionals and about 300 institutions in the Region. The available information resources were enriched with additional international databases, documents and periodicals. These resources include 8000 documents; about 800 training and learning materials; 43 international journals; 100 newsletters; and 19 CD-ROMs including bibliographic and full-text databases. All of these resources are being made available to CEHANET users. In 1997, CEHA distributed more than 6000 documents and 4000 copies of its quarterly newsletter and responded to about 500 information inquiries. Volume 7 of CEHA’s regional environmental health bibliography was compiled in 1997. Now it includes about 35 000 abstracts covering all the countries of the Region. Another important database was compiled to improve the access to the journals available at CEHA; this database cites about 8200 articles which are available with CEHA. Four databases on environmental health professionals and institutions in Egypt, Islamic Republic of Iran, Pakistan and Tunisia were compiled. By arrangement with the Regional Office Health Information Support unit, all these databases will be accessible through the Regional Office’s website. In addition to this, computer diskettes and CD-ROMs will be distributed to those who do not have access to the Internet. In order to achieve the second goal, two parallel approaches were followed: strengthening national information exchanges and networking capacity; and development of information processing systems and tools. A model documentation centre was established in the Republic of Yemen. It will be replicated in Lebanon, Morocco, Palestine and Tunisia. In collaboration with UNEP and WHO headquarters, human resources development activities were resumed in 1997. Eleven participants from Jordan, Lebanon, Palestine and Republic of Yemen were trained on CEHANET procedures, Internet, e-mail and other modern information technologies. Two information tools were upgraded and Arabicized in 1997, namely the CEHANET procedures manual and the environmental health subject analysis handbook. These tools will fill a gap.
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