WORLD H E A L T H O R G A N I Z A T I O N

ORGANISATION MONDIALE

REGIONAL OFFICE FOR THE BUREAU REGIONAL DE LA

EASTERN MEDITERRANEAN M~DITERRAN~E ORIENTALE

IIEGIONAL COMMITTEE FOR THFi EASTERN M E D I T E M r n

Eleventh Session

E M / R C ~ ~ / 8 26 Ju ly 1961

ORIGINAL: ENGLISH

Agenda item 12 (e)

RURAL mALTH

I INTRODTcTCTION

The countries of the Eastern Mediterranean Region have a common back-

bound i n h i story, t e r r a in and demography, Their ancient c iv i l iza t ions

have s p m g up as foc i i n different countries chief ly along the valleys of

t h e i r d v e r s and shores of t h e i r seas. The Nile valley, the Iran plateau,

the F e r t i l e Crescent and the Sind c iv i l iza t ions a re well-known and require

no fur ther description. The Aryans came original ly from the Iran Plateau,

and the Greek and Latin languages derived from the Sanskrit,

The majority of the countries of the area are traversed by large and

vast deserts, Therefore, the populations of the Region are mainly agrarian

and nomadic, Ci t ies with urban u t i l i t i e s have develaped t o a cer ta in extent

i n recent times, Public services .such a s the supply of potable water through

pipe-systems, e l ec t r i c i ty , sewarage and sewage farms, modern hospitals, were

introduced i n the large c i t i e s l a t e i n the nineteenth century and began t o be

more general i n the present century. . .

The whole Region has been from ancient times onward the scene of periodic

and devastating epidemics. Migration through the trade routes which brought

an exchange of c iv i l iza t ions a l so brought scourges of huge proportions which

spread from country t o country i n this Region where the main races of the

world meet, mix and join hands.

I1 COMMUNITY STUDY

To plan successfully f o r rural health work, a study of the c o d ~ y

and of the h i s t o r i c a l background of social and economic conditions i s

essent ial , (1)

(1) - See : Doc, E M / R c ~ ~ / 8. ~ d d . 1

Up t o the present, most of the l i tera ture on community development deals with

communitiesinwell developedcountries, Thereforeplanningfor ru ra lhea l th

i n our Region must take into account the composition and a11 the factors con-

cerning the rural population i n accordance with the local condi-tions,

One of the f i r s t and foremost duties of a health officer, responsible

for a certain community, i s to know about i t s history, people, geography,

topography, climatology, the type of soil, transport, administration, neigh-

bourhoods, population, composition of villages or c i t ies , industry, sources

of raw material and many other topical matters. S ta t i s t i ca l data must be

collected and i l lus t ra ted, Information on education, and such pertinent

questions are essential.

Cornunities are differently situated as to the amount of money they can

afford for schools, health fac i l i t i e s , leisure time pursuits, food, clothing,

housing and government, There i s considerable difference between a thriving

small cornnity, with a sound, well-diversified economic base, and one which

lacks this advantage. The type of industry likewise influences the tone of

the community's daily l i fe .

Our rural communities i n the Middle East, with the exception of the o i l

producing areas, are usually of the poor type, T h i s i s the whole crux of

the matter, and thus it i s often di f f icul t t o achieve i n health the required

standard i n a lifetime. The process i s a slow and prdtracted one, depending

primarrlly on budgeting the adequate funds. The prosperity of communities

depends, i n modern times, on industriaU.aati.on, Agriculture by i t s e l f has

ceased to be sufficient. It would be interesting, fo r instance, to study

the average income of the general run of families i n a community and evaluate

this i n relation t o health standards, Perhaps an investigation, such as the

estimaUon of the number of families needed t o support a grocery or other

type of store, would unravel the purchasing capacity of an urban or ru ra l

community, This canbe depictedwhen the figures are camparedwith co rn -

nitF es living i n highly developed countries and other developed countries , For instance, 250 families support one grocery shop and 2,400 a bakery shop.

There i s no record of such a nature i n the references of our Region, There

are large numbers of questions that must be answered i n each community,

Following are only a few examples:

List of various categories of stores

List of the type and number of physicians

Lawyers

Teachers, e t c . Average income of farmers i n the country

Co~muni t y indus tri a1 future

The formal structure of the local Government i s an important considera-

tion. A map of the conrmunity showing the different governmental units should

be prepared^

The need fo r cornunity planning i s evident, There has been no planning

of this sor t i n many of the countries of the Region, o r planning a t best has

been piece-meal, For instance, housing projects are planned without ade-

quate attention t o the community f ac i l i t i e s on which thei r inhabitalits w i l l

have t o draw, In a country of t h i s Region, i n one of the rural areas re-

cently reclaimed, houses were bu i l t of burnt 'bricks and adequately white

washed, but not only was the cost high, but they .proved unsuitable because

the customs of the peaple had not been taken into consideration, For ,

instance, they were used t o a different type of oven, and the small ovens

provided f i l l e d thei r houses with smoke, Moreover, the sloping roofs

allowed the rain to pour inside the yards, rendering them muddy during the

rainy season. Yet the houses had been bu i l t by expert engineers, The

f au l t l ay i n the fac t that they had been trained t o practice the i r techniques

i n well developed areas situated i n a different environment where an adequate

drairiage system was provided, It can thus be seen that cormnunity planning

ac t iv i t i es require coordination i f they are t o be effective. It i s necessary,

therefore, that a board be charged with the overall responsibility f o r conarm-

nfty planning i n i t s broadest aspects, It should help to coordinate planning

i n any of the fol lodng fields: health, welfare, education, industr ial deve-

lopment, physical aspects of the community, recreation, f i s ca l planning, etc,

The fac t tha t these types of planning go on relatively independently of each

other usually operates t o the detriment of the community. One of the chief

functiohs of the planning board i s to draw up a master plan or cornunity plan.

Such pmcedure has not as yet taken f i m footing i n our Region. It must be

stated, however, that i n recent years some countries of the Region have esta-

blished ministfies of planning and special boards and councils to deal parti-

cularly with public services, such as education, health, water supply,

u t i l i t i e s , sewerage, food control, nutrit ion, housing, the distribution and

density of population, recreation and others, Decentralization of administra-

t ion i n certain corntries of the Region has greatly augmented ac t iv i t i e s and

in te res t i n refom a t the provincial and even d i s t r i c t levels. Using the

basic democracies or national unions a t a l l levels s tar t ing from the vi l lage

upwards, i n taking active pa r t i n coordinated plaruling, and playing an appre-

ciable role i n cooperative, social and health work, i s a newly introduced

sys-tern, which i s watched with great interns$ and hope, Education i s the

most imporbant p i l l a r on which community development rests. In t h e countries

of the IVIiddle East, there are perhaps not more than one o r two countries where

75% of t h e i r children and youth have placements a t schools, Education i s

very much linked with publl c health i n many aspects, The prevailing diseases

are diseases of childhood. Epidemics h i t children severely and endemic

diseases prevai l among them, The schools are also the chief centres f o r

health education or they should be, Public health experts should take pa r t

i n the comprehensive planning, especially i n education. A largely agri-

cul tura l community w i l l have different school needs from a metropolitan

community, otherwise ru ra l youth ends up i n c i t i e s and i n addition Lo depriv-

ing the land of the required manpower, the psychological s t ress on these m a 1

tm irmnigrants i s significant, The public health off icer should be aware

of the personnel of the schools i n h i s domain, t h a t is , of the types available,

such a s cou~selars, school physicians, school nurses, dental hygienists, psycho-

logists, school social workers, special teachers f o r physically or mentally

handicapped children, etc, There are various aspects of a community which

are always of in te res t t o the public health authori t ies and should be studied

by them, such as i t s structure, the housing conditions, public recreation,

aids t o family l iv ing and child welfare, social insurance and public assistance,

provision f o r the handicapped, the aging, the migrant farm workers ahd the

displaced persons . 111 GEXE3A.L COMMENTS ON HEALTH I N RURAL &%AS IN THE

MIDDLE EASTERW COUNTRIES

I n attempting t o arrive a t a general picture of the quality of health

cam, one i s helped by certain indexes which are believed t o be part icular ly

important i n ref lect ing loca l health conditions more or l e s s directly,

Among the best of these are the infant and maternal mortality rates, Others

are the r a t e of s t i l l b i r t h s and the proportion of b i r ths i n hospitals

as opposed t o b i r ths elsewhere, The tuberculosis ra te i s par t icu lar ly indi-

cat ive i n t h a t since this disease can be largely controlled by man, a high

r a t e indicates possible neglect of modem controlmethods, (1)

The average annual amount pe r capita spent by a health department f o r

a l l the services e i the r preventive or curative including a lso the expenditure

by Municipality and r u r a l a f f a i r s i n t h i s Region rare ly exceeds the eqbivalent

of US $2, In the United States of America, a conrmunity of 20,000 t o 25,000

population could e q e c t t o have 18 t o 20 active prac t i t ioners of whom 3 t o 5 would be qual i f ied spec ia l i s t s - an i n t e rn i s t , a surgeon (possibly two), an

ear, nose and throat spec ia l i s t and an obstetrician, The number of people

needed t o support spec ia l i s t s i n the various medical special t iec can be e s t i -

mated only roughly, subject t o modification according t o the s i tua t ion of the

individual community, medical traditions, proximity of la rger communities

with many 2specialistis, and s imi lar items, Here are sane rough f igures merely

to give an appxoximate idea: (2)

Specia l i s t

In t e rna l medicine ( diagno stici.an)

Ful ly qual i f ied surgeon

Fully qual i f ied obstetrician

Ear, nose and throa t

Roentgenologist

Pathologist

Number Needed t o Support

I f we compare the above standards with our figures i n the various countries

of the Region, we f i n d marked differences, With the exception of a few count-

r ie~c, the number of physicians compared t o s i ze of population i s i n the r a t i o

of l i t t l e more -than 1 t o 3000,

I n cer ta in coiultries of this Region, there are e i the r very few physicians

o r none a t a11 who a re nationals of the same country, Such countries r e l y

t o t a l l y o r t o a large extent on expatriates, There a r e other countries which

spend an appreciable p a r t of t h e i r health budgets on the treatment of c t i f f icul t

ur c m i c msos bwtld( The sanatorium charges f o r a tuberculosis pa t ien t

abroad amounts t o US $200 each month,

(1) - See: Doc, E M / R c Y / ~ . A ~ ~ , ~ (2) Quoted from "Studying your C~mmunity~~, by Roland 3 , Warren,

Russell Sage Foundation New York 1955, page 200

There i s a severe shortage of hospi tal beds i n the Eastern Mediterranean

Region, although hospi tal construction i n recent years i s developing i n several

countries, New services such a s physiotherapy f a c i l i t i e s and personnel,

laboratory f a c i l i t i e s and personnel, and diagnostic and therapeutio X-ray are

being introduced more o r l e s s according to the development of each country.

A few countries have s t a r t ed t o think of e s t ~ b l i s h i n g ih t h e i r c~nrmurUtty hos-

p i t a l s , a system of r e fe r ra l t o public health nurses, home care programmes,

psychiatric services, rehabi l i ta t ion p m g r m e s , m d blood bank ~seuvices, etc,

The health d e p a r b n t s and health ministAes of the countries of the

Region a r e now growing i n cent ra l administrative organization from year t o '

year, Also it i s most gratifying t o point out the rapidly growing close co-

operation between these departments and t h e i r various sections w i - k the World

Health Organization. The majority of these health adhninistrations comprise

sections dealdng with ltRecords and Vi t a l Statist icstt , ttSariitationtt, ohborn-

toriesIt, itHealth Educationlt, tlPub31c Health Nursingn, tlMatemal and Child

Healthtt, ttCommunicable Disease Controllt and "Chronic JXsease C p n t r ~ l ~ ~ , There . - i s a special section i n each ministry f o r tIInternationa1 HealthN woxk, Nutri-

tion, r ehab i l i t a t i on, i ndus t r i a l health, dental health, and mental health are

often represented, In countries with extensive malaria programmes special

sections dealing with this problem are already i n existence. A s pa ras i t i c

diseases such as b i lharz ias i s and ankylostomiasis p m v a i l i n cer ta in count?des

of the Region, special departments have been well established f o r the l a s t

two decades,

To quote uPlanning f o r Health ~ e r v i c e s ~ l , ( l ) i n order t o carry on the

major public heal th services i n acceptable fashion, the following standards

are considered a minimum by author i t ies i n the f ie ld :

of Health Personnel Number of People Served

Modiccl Ilecilth Officer

Public Hcnlth Nurse

Sanitarian

Health Educator

Clerk

(1) Planning f o r Health Services: A Guide f o r S ta tes and- Comuriities Public Health Service Bullet in No.304, Government Print ing Office, Washingtm, 1950 '

In the Middle Eastern countries there are a few countries whi~h may

sa t is fy th5s standard buy the maj or i ty are f a r below, There are countries

without any public health service i n the true sense, A l l that they have i s

a, curative service. In the f i e l d of public health, the WHO Regional Office

has recently introduced several projects with the object i n view of advising

countries i n the f i e l d of health organization and preventive medrlcine, More-

over, the more developed countries have recently introduced decentralization

of health services bringing than t o the province level, The budget, however,

remains a t the central stage, and thus there i s no complete autonomy a t pro-

vincial or coaDmclnity levels,

Sanitation i n -the countries of this Region presents the moat d i f f icul t

problem, Community water and potable water f o r everyone has received great

attention &ring recent times, (1)

There are countries which are s t i l l d i s t i l l ing sea water, but have received

advisory assistance recently from the Intornational Bank and from our Regional

Office for the puqose of procuring underground vztcr. On the

other hand, there are other countries which have executed extensive water

projects f o r the benefit of , the greatest bulk of the population (up t o 80%).

It i s worthy of note that certain countries with vast ar id zones have

succeeded i n obtaining sufficient water f r m artesian wells t o supply the i r

main c i t i e s (Saudi Arabia),

The problems of collection and disposal of garbage have been l e f t un-

touched i n ru ra l areas. This i s a grave hea1.b problem, The house f l y

remains the pestilence of the village. Disposal of human excreta i s another

problem which has not been solved i n rura l d is t r ic ts , but control of rodents

and insects ' i s beginning to receive more attention. The control of comuni-

cabls diseases especially those that are quarantinable, i s the main function

of the health offices of the Region, The extension of rural health services

m y aufpnt and improve work i n this f i e l d and i n that of chronic diseases,

and of cancer which i s an important problem i n rural health i n th i s Region,

as it i s comparatively more prevalent i n the bladder due t o bilharziasis of

the urinary t rac t ,

(1) - See : Annex I giving data on piped water supplies

IV RURAL HEALTH AND COMMUNITY DEVELOPMENT I N TI@ COUNTRIES OF THE EASTERN MEDITEIZRCWEF REGION

I n the preceding chapter an attempt was made t o point out the great

need f o r studying the community with the object of planning heal th services.

This f a c t has become evident as a r e su l t of f i e l d experience. Towards the

end of 19b7# the Rockefeller Foundation car r ied o u t an experinat i n con-

junction with the Egyptian Government i n f ive vil lages, the cos t of which

amoundzLng to L,E,l$0,000 was shared by both parties. I n the f i n a l report

submitted by the Foundabi.on a t the end of 1951, it was s ta ted tha t t he ex-

p e m e n t had not a t ta ined i t s objectives because a11 e f fo r t s had been con-

centrated i n the heal th f i e l d only, neglecting the socio-econodc aspects;

and the integrat ion of health i n commzlnity development schemes.

Rural heal th seguibes were not organized on a methodical basis i n any

par t icu lar country before 1931. The year i n which the League of Nations

held i t s f i r s t conference on r u r a l health i n Geneva, recommending %he in te-

gration of the curati.ve and preventive heal th services i n centres t o serve

from f ive t o f i f t y thousand of the population. After that , countries

s t a r t ed t o put t h i s recommendation in to operation. The second League con-

ference held i n Bandung t o study and evaluate the r u r a l he< l t h units organized

by the various countries recommended the great need f o r another conference t o

be convened i n 1939 i n Geneva t o study the whole r u r a l problem i n a l l i t s

aspects, i, e. col lect ive investigation including health.

T h i s l a s t conference did not take place due t o the outbreak of war.

It was the Beveridge Report t ha t stimulated the Health Department of Cyprus

t o act ion and t o begin a d i r ec t a t tack on rura l health problems. A nominal

rura l health service was i n f a c t established there i n 1900, I n 1902 there

were eight r u r a l medical officers; by 1929 t h e i r number had increased t o 28.

But these jobs were part-time only, f o r doctors who were also i n pr ivate

practice. The d i s t r i c t s they had t o cover were immense, Thus the time

they could spend i n each v i l lage was l imited to a few hours - j u s t enough t o

see the s ick who presented themselves, If the ru ra l medical o f f i ce r ordered

medicines these had to be collected from a d i s t r i c t di~pensary, which might

be many miles from the vi l lage, Voluntary societ ies were formed t o deal

with diseases like tuberculosis, The provision f o r antenatal and infant

welfare work was rudimentary, The posit ion i n the municipalities was bet ter ;

the towns themselves were responsible f o r the medical services within t h e i r

boundaries, In 1943 plans for radical action against country ill-health

were laid, These were f o r rural health units, centred on key villages,

adequately staffed and working through sub-stations of varying sizes over

an area with 20,000 t o 30,000 people. Each uni t wuuld have three t o four

autlying village sub-stations, with possibly extra cl inics rn i n other

villages. The sub-stations were t o be equipped t o deal with routine oases,

including midwifery cases and each would be able to take i n an occasional.

emergency case for temporary in-patient trea-tment . A m a l l hospital with

perhaps eight beds was t o be attached to each central unit, Complicated

cases would be sent on to the d i s t r i c t hospitals, and a l l serious surgical

cases t o the hospital a t Nicosia, which would have to be especially enlarged

and equipped t o deal with them.

A typical central un i t was t o be staffed by a medical officer, four mid-

wives, two health visitors, a health inspector, an assistant health inspector,

two nurses, four sanitary labourers, and i n addition, a clerk, a compounder,

and a laboratory assistant. The sub-stations might be under the charge of

a medical officer, a nurse, or a midwife. The main building fo r each unit

would contain rooms for conferences and lectures, c o n s ~ l t a ~ o n s ~ records

and stoms, Separate rooms would be needed for the oculist and the dentist.

The laboratory and pharmacy would need accommodation, Wherewr there was a

hospital there rnust be special nursest quarters attached. The more impor-

tant sub-stations too would need ,special buildings, though the smaller ones

could be housed i n a village room. In a l l , eleven or twelve such d t s were

needed In cover the country. When one unit was opened the people were -to

be expected t o give a t l eas t the land f o r building. Village girls were

chosen t o t ra in i n the c i t y as nurses to serve i n their centres on the i r

return. h g u l a r ante-natal andinfant welfare cl inics and out-patient dis-

pensari'es were started. Other welfare clinics were made available, especially

f o r healthy people who wanted t o keep fitj indeed, the major emphasis of the

whole service was on maintaining health, Such cl inics were also opened i n

some 'outlying villages, served from the unit. The idea of learning how t o

keep healthy proved attractive, Whenever a case came to the clinic, the

mother or relat ive was taught how to look a f te r the patient, When the

mother took her baby there fo r advice on feeding she was not given the food

t o take away u n t i l she- has been taught how t o use it.

E M / R c ~ ~ / 8 page 10

Health v i s i t o r s followed up by ca l l ing on the c l i n i c pa t ien ts a t home, so

t h a t they could give more help and advice i f necessary. Women whose homes

were unsuitable could leave t h e i r babies i n the c l in i c1 s hospital, o r t o one

of the oentral hospitals. I f they had t h e i r confinements a t home properly

t ra ined nddwives looked a f t e r them.

Turning t o another country of the Region we come to Egypt which'slarted

ru ra l heal th reform i n 1927, when the Government issued certain health legis-

l a t i o n dealing with vi l lage sani tat ion and budgeted funds fo r the proviaion

of potable water supplies f o r r u r a l areas and f o r establishing hospitals i n

the chief towns of d i s t r i c t s and cer tain r u r a l areas, where treatment was

offered f r cc c;f charge, In addition, i n view of the great prevalence of

endemic diseases and commwnicable eye diseases, special mobile units were

provided' t o deal with the treatment of these infections. The Government

a l so began t o establ ish maternity and chi ld welfare centres i n urban and ru ra l

d i s t r i c t s ,

I n 1929 the Rockefeller Foundation i n Bahteem (a vi l lage near Cairo)

introduced the bore-hole l a t r i n e i n the houses of the vil lagers, but the

experiment fai led, due t o the changing l e v e l of subsoil water, but mainly

aue t o the neglect of maintenance, On the other hand t h i s experiment demon-

s t r a t ed that the general'use of the l a t r i n e i n the great majority of the

houses of -the v i l lage had caused the incidence of worm diseases such as

ankylostomiasis and ascariasi s t o decrease appreciably by the end of the

period of observation (f ive years), but i t had no recognizable effect on the

incidence of b i lharz ias i s ,

However, the progress i n rura l reform continued, I n 1934, a decree was

s e t fo r th by the Government establishing boards i n the provinces t o be charged

with the execution and operation of reform projects concerning health, edu-

cation, and public works. Although the progress was hampered by the minis-

t r i e s which .i brived towards centralization, these rendered valuable services

i n the f i e l d s of elementary education and i n making and improving roads.

They a l s o formed the nuclei of loca l g o v e m n t s .

During 1936 .a special department headed by an under-secretary t o deal

with public u t i l i t i e s was established by decree i n the Ministry of Health,

The main objectives of t h i s department made more wide-spread the provision

of potable water, f i l l i n g i n the borrow-pits, pools and swamps and the repair

and sani tat ion 9f the water, closets, and drainage system of mosques.

~M/lU11/8 page 11

During 194.2 a further advanse i n rura l health was achieved through the

enactment of new bgislat ion. Departments of sanitary engineering were

created under the provincial boards and the departments of Rural and Health

Affairs, *The chief aims of this new health legislation were the improvement

of health, of the villages and the protection of peasants against diseases and

in .par t icular to take care of the following problem$:

(1) The pmvision of potable water t o villages,

(2) Keeping the villages clean by disposal of refuse.

(3) Fil l ing i n the borrow-pits, pools and swamps,

(4) I~groving or establishing new water supply and closet system i n

mosques and constructing public bathirig establishments, fo r adults and school

children . ( 5 ) Construction of sanitary washing stands f o r clothes, and markets

f o r food and meat,

( 6 ) Drawing plan-maps for each village . t o ensure future extensions t o

be based on pruper sanitary design,

(7 ) Improvement of the house of the peasant.

(8) E s t a b l i s b n t of health centres t o serve 15,000 of the population.

Moreover, the Ministry of Social Affairs established i n 1939, s tarted t o

build and furmi& social centres i n villages t o deal mainly with raising the

social, s tatus of the villagers dnd t o care fo r health, especially maternity

and child" welfare. I n spite of the efforts of the boards, reversion ' to

centralization of rura l health service took place i n 1947, when it was decided

tha t the Minis t ry af Publlc Health should shoulder the responsibility of esta-

blishing rura l health units. For this purpose the country was qvided $nto

817 zones with one unit i n each. Approximately two hunasd health centres < 8

were erected a t a cost varying between ,45,000 to 60,QF Egyptian pounds for

each centre, The centre comprised an out-patient department, infant welfare

clinic, and comunicable eye disease clinic, and beds fo r patients suffering . n

chiefly from internal diseases, particularly endemic bilharziasis and para-

s i a c anaemias, as well as beds f o r maternity and minor surgery. Each

centre was provided with a dispensary and treatment was. offered free of

charge.

After the second World War ru ra l health entered i n t o a new phase, The \

World Wealth Organiaation a s s i s u n g i n this f i e l d of health, car r ied out ex-

periments i n order t o f i n d out the bes t methods and schemes which might lead

to success, A centre was established i n Ceylon i n one of its rural areas t o

s e m a popula'don composed of 15,000 and another i n Salvador to serve 9,000

people, This plan was to cornprisea,llthe services, c o m n i t y development,

social and health and t raining of personnel together, I n Ceylon, however,

health and education were combined, while i n Salvador the a c t i v i t i e s of the

centre were confined to heal th only. I n 1951 the World Health O~gar&zation

recommended to the Egyptian Government thz t they establish another centre on

principles similar t o those mentioned above, and t h i s was subsequently &neb

Each experiment brings fu r the r knowledge and, therefore, from the work

of the Qalyub project very useful information on the subject has been dedved

f o r workers i n t h e f i e l d of rura l health. (1)

Following such specif ic demonstrations as tha t i n the Qalyub area, the

great s t ep forward which marked the most recent progress i n ru ra l health has

been the introduction of the community development programme which includes

the construction, equipment and s ta f f ing of the combined units,

The ultimate objective of community development, a s l a i d down by the

Urlited Nations f o r community development and related services, i s balanced

development of the area i n the l i g h t of the loca l needs and resources through

the use of modern technological and sc i en t i f i c aids and introduction of an

integrated approach, team relationship, administrative coordination and

peoples1 part ic ipat ion i: partnership w i t h the Government on a self-help

basis,

The immediate objectives of community development are: increasing

agr icu l tura l production, eradicating or reducing human, ca t t l e and cmp

$Iseases and epidemics, upgrading ca t t le , improving sanitation, expandng

health, maternity and chi ld welfare services, providing more and b e t t e r

roads, water supply and other f a c i l i t i e s , working with cooperative societies,

youth clubs and v i l lage councils, organiaing meetings, study tours, cinema

shows and l i b r a r y services, expanding educational f a c i l l t i e s through primary

and nursery sChools and introducing home and ru ra l industry,

(1) - See: EM/RCU/~.A~~.~ A

In the United Arab Republic i t i s considered that thei r community

development programme which was introduced i n the Egyptian Province and

recently i n the Syrian Province i s the most important undertaking i n social

reform, In the former Province, i t was intended t o erect 864 combined units,

each of them to serve f i f teen thousand of the inhabitants, The Cotal cost

of the builCtengs and of equipping each un i t was L.E. 37,000, while the annual

budget i s approximately L.E. 11,000, Each unit comprises a m a l l hospital

provided with 14 beds and an out-patient department, a model school, children's

home, an agricultural f i e ld f o r experiments, a show room, lecture roam, and

villas and houses fo r the staff.

The abis of the programme are t o develop socio-economic conditions by

training the people to .ass is t themselves i n thei r commwnity;tomake ccmpxehensive

sstudies of the local social, geographical, historical conditions as well as

populatd.on, local government, culture, education, health and recreation.

Cooperative societies, including the elected members of the National Union

am active i n t h i s f i e l d of work. The special is ts of the conibined unit give

a l l the required technical assistance. Periodic meetings are convened i n

the lecture h a l l for ~ s c u s s i o n s i n the various subjects pcr t l amt to rura l

development. Films are exhibited. A l ibrary i n each unit serves the

readers, The childrent s home copes with the care and feeding of the f i f t y

children during the day, under the supervision of a young educated woman

from the village. The care of youth i s given particular attention by pro-

viding sports and healthy recreation. Health, agricultural and educational

exhibits are organizedfor public information. There are also two acres of

land used as a small fam t o supply the peasants witJn seedlings and young

trees, and f o r the cultivation of vegetables and f rui ts . Provision of

mechanical sprayers of insecticides i n order t o protect the crops has proved

one of the most useful %act iv i t ies of the unit. Special breeds of ca t t l e

have been utiUzed i n order t o improve the local breeds, and centres fo r

a r t i f i c i a l inseminati on i n the provinces have been established. Poultry

breeding, apiaries for honey production and breeding of special types of

rabbits are among the many activi t ies. Study of the possibi l i t ies of rural

industries and raw material resources are among the endeavours of these com-

bined units. The resources of each zone are completely investigated.

Attempts are even made t o find out which places might a t t r ac t tourists.

Training i n the rura l industrial f i e l d of workers and school children is

another f i e l d i n which efforts are made.

There i s a section fo r maternity and chi ld health, an out-patient depart-

ment and fourteen beds, During l9&, over a quarter of a million (232,000)

pregnant wamen were %ken care of, 80,000 specimens of blood were examined

serolo@.cally f o r syphilis, 473,000 children v i s i t ed the uni ts , and 322,000

home v id t s were made to mothers and children, The t o t a l number of out-

pat ients was 1,653, 564 and in-pat ients 34,272, Half a mill ion were examined

for schistosoma haematobium resul t ing i n 39% positive cases, and 314,627 f o r

schistosoma mansoni giving 3,5$ positives,

The s t a f f of the health centre i n the combined unit consists of a medical

doctor, one sanitarian, one nurse-midwife, two ass i s tan t midwives, one ass i s -

tan% nurse, one laboratory technician and one clerk. I n addition, there i s

the pe t ty s t a f f consisting of one cook, three orderlies, three female workers

and a gardener, There i s a severe shortage of sani tar ians and nurse-ddwives,

There. are no public health nurses t o carry out the important duties of home

v i s i t i ng and heal th education. There are 240 elementary schools i n the com-

bined units f o r childmn and adult education, the former i n day classes and

the l a t t e r i n evening classes. The s t a f f of the health uni t gives a public

health programme t o the pupils, t r e a t s the sick, protects the healthy by

health educakion immunization and other means, t r a ins boys i n f i r s t - a i d and

girls i n p rac t i ca l nursing and chi ld care, and a lso gives t ra ining i n the

f i e l d of the application of insect ic ides and taking p a r t i n eanitation as

f a r a s practicable,

There a re marked a c t i v i t i e s I n agriculture carr ied out by the spec ia l i s t s

of these combined units aimed a t t ra ining the peasantry and establishing use-

f u l ru ra l industr ies , Social work, especially i n the f i e l d s of cooperative

societ ies i s being conducted within the programme of community development,

The Public Information Section has introduced cul tura l and recreational films,

established reading rooms and museums i n a number of vi l lages, Foreign aid

i n the form of milk i s being distributed. There i s an endeavour t o introduce

environmental sani tat ion by ins t ruc t ing the peasant to e rec t a sani tary l a t r i n e

i n his house, Water i s provided t o the vi l lages. The work i n t h e f i e l d of

sanitation, however, has not progressed. Sufficient number of e f f i c i en t per-

sonnel, provided with adequate funds and equipment are required t o concentrate

their e f fo r t s over reasonable period of time, i n order t o achieve tangible

ref om.'

The c m t y ' development programme i n the Province of Syria, United Arab

Republic, (') has sucqes sfully passed through numerous vicissitudes but i s now

well on the' way t o becoming a permanent and expanding national programme, A

ten-year natdonal programme fo r setting up 110 projects, including seven zonetr

of the Syrian RegLon,. has been, accepted i n principle, and included i n the

five-year plan, Funds have already been sanctioned for eight p i lo t projects

expected t o cover a population of over 200,000 i n eight nahias (administrative

sub-divisions) ,

In Ethiopia, the Gondar College which i s technically assisted by WHO and

I C A has been training auxiliary staff f o r health services and rural health

centres. L project of a supervisory team for rura l health i n Ethiopia which

w i l l be provided by WHO staff (senior adviser, sanitary engineer and public

health nurse), i s budgeted t o s t a r t i n 1961.

In Iran, rural health ac t iv i t i es have been developing according t o 'the

economic, demographic and geographic conditions of the country. In 1951, on

the request of the Iranian Iil'inistry of Health, the World Health Organization

entered th i s f i e ld giving technical assistance. t o the Govenunent. A p m u -

(*) Environmental sanita- minary survey was carried out by a WHO consultant,

tion has been given special a t tent i on, particularly training. (a)

In Iraq, rural health was surveyed i n 1951 by a WHO consultant.'')^ rural

health demonstration and training centre was established by the Government

and assi'sted by WHO.

In Israel, them i s a d i s t r i c t organization, as fo r example, the Central

Health Distr ict with i t s headquarters a t Ramla and four sub-districts, Each

of these centres has a population of approximately 25,000.

A s regards the administration, a l l ministries are represented both a t

d i s t r i c t and a t sub-district l e v b l ~ so that close coordination of ac t iv i t ies

having a oommon interest i s possible. , There are 240 communities in the

Central Mst r ic t , of which 200 are below 1,000 populatiion~ they include

t h i r t y Kibbutzin. The . la t ter are cornunities i n which l i f e i s l ived on

See : 7

(2) A PreUminary Survey fo r a Rural Health Demonstration Area i n Iran D r , Crichton Jones, ~ / P H A / ~ L - December 1952

(3) - See : E M / R C L ~ / ~ . A ~ ~ . 3

(h) Iraq Rural Health Survey, Dr . W,E. Holmes EM/PHA/~o February 1952

EM/RCLU 0 page 16

a communalbasis; We family has no income, infants are k e p t i n communal

homes having a f ixed s t a f f , and the infant mortali ty i s low, Meals a re

provided on a communal basis . In these comrnw?ities, agriculture and small

inCiustxLes are the main occupations. Prof i t s earned are not distxSbuted but

used on behalf of the community, whose leaders are elected. Them are many

different types at' kibbutz, and the pat tern i s not fixed along the general

l i nes described above, In some, f o r instance, families can keep t h e i r

children with them,

With regard t o sub-districts, the s t a f f consists of a health off icer ,

a nurse supervisor and a chief sanitarian, epidemiologist and malar;.iolo@.st

a t top levelb with public health nurses, sanitarians and other 61uiUasg

persoanel acoording t o the needs of the sub-district, The s t a f f of the

sub-district undertakes work i n the f i e l d af maternal and ch i ld health,

school health, sani tary supervision, i ndus t r i a l hy&ene, health education

a s well a s antimalaria campaigns and e p i d ~ o l o @ c a l sumreys where these

a re needed, The function of loca l au thor i t ies i n this f i e l d i s one of

sewage and garbage disposal, water supplies, the provision of maternal and

chi ld health centres and the i r maintenance, and they share i n the sa l a r i e s

of s t a f f working i n them,

Curative work i n d i s t r i c t s i s mainly carr ied out through the Workerst

Sick F'und (Kupat Holim), which i s a voluntary health organization based on

contributions and providing a comprehensive health insurance scheme, (1)

WHO EMRO have paid special a t tent ion t o introducing rura l health

techniqves i n t o Lebanon, One pro jec t was established i n the Southern

Province, and a more recent project has been i n s t i t u t e d i n Halba i n the

North of Lebanon. A s the work i s jus t beginning, i t i s hoped t h a t progress

w i l l be d i s t inc t ly pronounced and i t s evaluation conducted i n sc i en t i f i c ways,

In Pakistan, the new scheme f o r rural health i s being developed, The

new type of centre i s an adequate building, having i n i t s v ic in i ty housing

accomodation f o r two doctors and auxiliary s t a f f , Each centre and i t s

three sub-centres w i l l serve 50,000 of the population.

(1) - See: Doc, EM/PHA/~o, Chapter JV , page 4

Specifically trained health technicians w i l l talQ care of the sub-centres

and tbe doctors w i l l v i s i t these i n rotation, The scheme i s adequate fo r

integration of rura l health work,

I n West Pakistan, it was announced early th is year that ten demonstra-

tiLon and f i e l d training health centres w i l l be opened durima the current

financial year,

These centres wi l l be located i n Peshawar, Rawalpindi, Lahore, Jhelun,

Sheikupura, B ahawalpur, Nawabshah, Hyderabad and Quetta distr icts . The

buildings f o r these -ten centres w i l l cost the equivalent of about $675,000.

The e n a r e expencliture w i l l be borne by ICA. Most of the equipment as well

as transport w i l l be supplied by UNICEF.

Of the ten centres, five w i l l also serve as training centres. They w i l l be located a t Khairabad (~eshawar) , Uch Shariff (~ahawalpur) , Tando Jam

(~yderabad) , Pishin (Quetta) and Lulliani (Lahore) , The se centres w i l l

have separate buildings for the accommodation of staff t o be trained.

Health councils w i l l be s e t up i n a l l urban areas throughout the

West Wing.

A s f a r a s possible, related projects should be located i n the same areas

a s the p i l o t projects i n community development and coordinated w i t h each

other. In the Sudan, th i s highly desired coordination has found i t s way

in to the rural health demonstration area a t E l Huda i n the Menagil extension

of the hairs Irr igated Area as a part of a p i l o t scheme i n camunity develop-

ment, to be established by the Government with assistance from WHO and UNXY31i'

i n order to provide the following f ac i l i t i e s a t E l Huda: an integrated

health centre f o r both curative and preventive services including maternal

and child health, a dispensary f o r out-patients and hospital accommodation

fo r twenty patients (six general male, s ix general female, four maternity,

four przediatric), laboratory and immunization services and school health

services t o the population of the area covered by the project are t o part i-

cipate i n the balanced social and economic development of the area 4.n co-

operation d t h the d e p a r h n t s of agriculture, animal resources, education,

commerce (cooperative division), information and local government, and by

coordination, where possible, of the extended health services with other

phases of socio-economic devslopment, The following services f o r general

q-ty development w i l l be provided: (1) an ,agx5cultural centre conc@ma

E I V I / R C L ~ 8 page 18

with poultry, ardrnal husbandry am3 milk production; (2) a horticultural

centre; (3) a training centre f o r social Workers and village craftsmen;

(4) model housing for workers; ( 5 ) schools, including secondary schools,

The main objective from the health point of view i s to develop the

services existing i n the Menagil Extension of the Gezira Irrigated Area in%o

a model system for integrated preventive curative health service as a pattern

fo r otha* aread, and to develop concurrently a suitable system df administra-

tion f o r tbese services, The area 09 act iv i t ies wi l l be eighty-?five villages

served a t present by the eight dispensaries, A l l these dispensaries are

within a radius of 25 kilometres from E l Huda and the t o t a l population of the

area i s estimated a t 68,500, t o which number may be added 20% of migrant

labourers,

Rural health i s being given special attention i n Jordgn and Tunisia, a s

well as i n other countries of the Region, In Yemen, the WHO Training Centre

a t Sana 'a, where sanitarians and community nurses are being trained wi l l pra-

vide staff f o r the future rural health posts i n villages. It i s planned t o

provide Yemen with another centre i n Taiz and a mobile unit, The newly con-

structed roads i n Yemen w i l l f ac i l i t a te future health act iv i t ies i n the

country.

V THE ENDE1MIC DISEASES LOAD

The countries of the Eastern Mediterranean Region am characterized by

t he prevalence of certain endemo-epidemic diseases, Malaria tops the list,

From time immemorial these diseases spread along the routes of trade from

Asia t o Africa and vice versa, Cholera has prevailed i n epidemic form i n

B engal and across the sublcontinent of Indo-Paki stan and i n a l l neighbouring

countries, Smallpoxis endemic i n several countries. Even yellow fever

i s s t i l l ravaging the south-eastern African wing of the Region. Enteric

fevers, diarrhoea1 and dysenteric diseases are endemic i n a11 the countries,

Trepanomatosis, and even liala-azar and onchocerciasis are endemic i n c e r t d n

countries, Ankylostomiasis i s endemic almost everywhere i n the Region,

Bilharziasis i s a permanent endemic scourge i n certain countries of

the Region, It i s widely spread i n the Egyptian Province of the United

Arab Republic, Iraq and Sudan, due to the extensive irr igat ion and cultiva-

tion developments i n these countries, In other countries it i s present i n

localized controlable areas, i.e, i n Libya, Saudi Arabia, Somalia and Tunis;

EWRCLLI~ page 19

Trachoma i s also prevalent i n the Region. Active trachoma cases among

school children$ i n Addis Ababa i s 36.4$, i n Gondar 50;1% and i n Harrar &&%. In Eritrea, i n certain local i t ies the incidence i s 29.0% and i n others 80%

and 97%.

In Iran active trachoma incidence i s 19.3% t o 38.6%. The highest inc i - dence i s i n the Egyptian Province (UAR) being 90 t o loo$, ( 1)

hiberculosis prevalence i n rural areas i s not less significant than i n

urban areas, (2) Integration of control of tuberculosis i n rura l health

work i s receiving a great deal of attention,

Malaria, surveillance should be integrated i n rura l health work, wherever

an eff ic ient system i s established. Malaria i s highly endemic i n the great

majority of the countries of the Region. For this reason WHO i s actively

engaged i n the eradication of th i s disease,

The endemicity of these diseases has been given great attention by

Governments and i s draining a great deal of the public health funds, To

deal' with bilharziasis, treatment and control units have been established

i n Iraq, S u m , and the Egyptian Province of the United Arab Republic fo r

three decades a t least. Most recently i n the Egyptian Province (UAR), the

Ministry of Public Health has established two hundred units for the mass

treatment and control of endemic diseases, each to serve 10,000 of the papu-

lat ion cultivating approximately 5,000 acres, Each of these units i s

staffed by a medical doctor, a nurse, a laboratory technician, an assistan%

sanitarian and four health labourers f o r the control of snails and insects.

There i s a dispensary and one bed i n the unit for emergency, Health educa-

Uon posters are provided f o r the benefi't of the patients. There are also

f ac i l i t i e s for digging wells and constructing latrines.

%e units are wooden structures &sisting of four rooms and verandas

well shaded Por the patients waiting fac i l i t i e s . The cost of cmstruction

and equipment i s approximately L.E .l, $0 and the annual running expenses are

equal t o that amount. These units t r ea t a l l bilharziasi s suffering indivi-

duals i n thelCommunity. Eye diseases are also treated, as well as a l l

other endenzi~ diseases. It i s the intention a t present to establish a

(1) - See : EM/~c11/8, ~ d d , 4 A (2) - See: ~J!4/~~11/8.~dd,4 B

E M / R c ~ T / 8 page 20

sub-centre lib this uni t i n each vi l lage of 5,000 inhabitants t o be run by

t h q cooperative society and Union members i n each vil lage, It w i l l be aided

by the Government, giving t o each un i t a f inancia l contribution t o cover the

salaries of the s t a f f ,

These sub-centres . W n l y . deal with the endemic diseases load of the

community. They must be s i tuated within reach of the inhabitants so t h a t

they w i l l receive the maximum benefi t from them, These vi l lages carry out

the services of reg is t ra t ion of biological events and control infect ious

diseases; arid can be eas i ly equipped t o cover other necessary r u r a l health

services f o r the vil lage,

Reference could be made here a l so to a pmjec t which i s being car r ied

out, i n the Province of Egypt (UAR) by the Government ass i s ted by the USOM

i n E gypt which deals with land reclamation and resettlement programmes in-

cluding health care among i t s various community development activitdes. (1)

V I CONCLUDING COMMENTS

I n the preceding chapters an attempt has been made to depict the s i tua-

t ion of r u r a l health i n the Eastern Mediterranean Region. I n the majority

of i t s countries continuous e f fo r t s t o promote health i n urban centres have

been i n existence f o r a long time, Recently, however, a t tent ion has been

given t o improving conditions i n ru ra l areas. Although it can be s t a t ed

tha t sani tat ion has been e i the r very l i g h t l y touched or not a t a l l , curative

services have been spreading a s Itrural health centresI1, nrural medical ser-

VIJcesI1, or I1rural health posts1I, It should be pointed out, however, t ha t

control of comrnpity infections, the education of the individual i n the

pr inciples of personal hygiene, the orgayliaation of the medical and nursing

services f o r the ear ly diagnosis and preventive t r e a t m n t of disease, are

only one aspect of the overal l programme, only one l i n k i n the chain, one

phase of a complex undertaking i n the development of the soc ia l machinery

which w i l l ensure t o every individual i n the canmunity, a standard of l iv ing

ade,quate t o the maintenance of health,

There are problems of great magnitude which face the ru ra l population

of this Region, including the unfavourable socio-economic conditions and

See : -

~e existing morbidity load, Themfore, planning by a l l concerned should be

an essential primary actLon, A master plan must be prepared drawn on the

findings of community studies t o include a l l aspects of .health. socio-economic

and educaki onal desf gns ,

Integration i n a l l ac t iv i t ies and services and administrations i s the

first essential f o r success. Concerted integrated action i n the services

of health, cooperatives, agd.culture and horticulturet social work and edu-

catf on i n community &velopment cen tires should be the r ight policy to be

adopted.

A t present, ministries hold firmly t o the i r independence, and this ex-

plains the uncoordinated action. The Ministries of Social Affairs construct

community development centres, while the Ministries of Public Health, on the

other hand, establish independent health centres ei ther neahy or somewhere

else. This results i n duplication and weakening of the serviceks. However,

regionalisation which has already been adopted by certain c o u n k e s of the

Region w i l l resul t sooner or l a t e r i n bringing these services together, in te-

grated under local provincial governments,

Integratirn must be practiced i n a l l the aspects pertaining t o rura l

services. It must be ins t i tu ted i n training of persmnel i n medical care

programmes, i n studying problems t o be solved, i n identi ty of objectives of

both , . preventive and curative programmes, and also i n those aspects of local

health that a re not exclusively medical, such as nutrition, housing, culture,

l iving standards, etc.

There must be integration of health education in to a l l the services,

especially i n schools i n the curriculum of general education, i n the pro-

graqmqs of general culture and i n a U $& veins of the combined community

work,

Ways and means must 'be planned for the integration of the work of sur-

~ e i l l m c e ,of malaria eradication, tuberculosis control, communicable diseases

contml, trachoma control, bilharaiasis treatment and control a s well as

diarrhoea1 diseases among other great problems of health i n the Eastern Bed-

The geographic integration i s of paramount importance f o r the promotion

of health both i n urban and mral d2stricts. To explain this term we refer

E M / R C ~ ~ / ~ page 22

t o the dependency of ru ra l areas on the urban highly developed services i n

the f i e l d s of ecommics, culture, 80c!i$l f i e l d s and even more evidently i n

the f i e l d of medicine. Good medical services i n rura l a E a s depend on e f f i -

c ient urban centres. On the other hand, good service i n ru ra l areas w i l l

relieve urban services from the rura l epidemiological reservoir, The rura l

centre or health post w i l l a c t a s the simplest nucleus or advance guard, and

w i l l become a mere l i n k connected with the more cmplex organizations i n

small towns o r la rger ru ra l loca l i t ies . I n this way, the simplest super-

s t ructure of the i n s t i t u t i o n a l network i s created: the rural-urban heal th

d i s t r i c t . Thus, a decentralized organization should be one with cer ta in

autonomy with respect t o financing and supplies so t h a t from t h i s a health

region w i l l emerge with a sea t provided with the regional cent ra l hospi tal

and the cent ra l health laboratory.

I n a medical care programme i n rura l areas, s t r e s s should be placed on

the proper t ra in ing of personnel before and during the time they enter i n t o

sewice , The physician i s expected t o lead the way i n the campaign f o r

overal l cornunity improvement, and he mst be thoroughly prepared f o r such

work, A thorough university t ra in ing i n public health and a pract ice period,

however short, i n a rura l area w i l l always be a gurantee of a s o l i d and a l l -

rounded development, whatever f i e l d of medicine i s chosen, Such t r&ning

will , a t l eas t , throw l i g h t on the vocation, character, personality and soc ia l

awareness of young physicians and tha t i n i t s e l f would be extremely valuable,

A revision of the curr icula by the univers i t ies i n the Region i s highly

necessary t o help us i n our endeavour t o achieve our goal i n a reasonable

time, Courses i n ru ra l health f o r physicians a re e s sen t i a l to them i n

order t o awaken i n them socia l awareness, It i s essent ia l f o r doctors t o

have a pre-orientation internship f o r two to three weeks a t health centres

where the candidates should observe the operation of preventive c l in i c s f o r

pre-natal cam, nursing babies, school children, etc, , and learn the adninis-

t r a t i v e procedures used i n loca l public health jurisdiction, Another course

of two mon-bhsr duration should be arranged a f t e r completion of the internship

a t a health centre well organized f o r training, p r io r to engagement i n t h e

ru ra l heal th service.

In some c auntries of t h i s Region, physicians who have done outstanding

work during t h e i r service i n rura l health, are granted fellowships t o f ollaw

a course of study i n public health or t ropica l medicine and hygiene i n order

t o obtain a diploma. In Venezuela, rural physicians who may be called upon

t o fill 'porsitions of ' a higher category, on an intermediate level between -he

regular rural 'physicians and the public health officer are given a basic

course i n rura l public health, last ing seventeen weeks i n the following fieldsr

public health, administration, Btatistics, epidemiology, sariitation, tuber-

culosis, venereology, maternal and child health, shcool health, health educa-

tion, Laboratory, nutfition, leprosy and malari ology.

Following each course of training, the physician should find himself

again serving rura l health until1 he f ina l ly becomes highly competent, envi-

saging clearly the concept of integration and keenly aware of the constant

dependency between urban and rura l areas, Scientific training of physicians

should be maintained by pmviding ample opportunity fo r them t o read medical

journals and t o attend lectures by eminent professors,

Training courses fo r auxiliary persoqnel before and during the time they

are i n service, should be organized. Several counCries of the RegLon have

establi&ed programmes and training centres f o r auxiliary staff , and an

appreciable number of these projects am technically assisted by WHO EMRa,

The medicel care programme should a i m a t attaining Ln rural health the

efficiency 'which would @.ve adequate service to the individual as offered,

or almost as rhuch, Co the urban dwellers. The health uni t and the hearth

centres should be the l ink which would f ac i l i t a t e treatment of d i f f icul t cases

at the referral hospital, u t i l i z e laboratory fac i l i t i e s , X-rays, etc,, which

exist a t urban centres. This network arrangement can be achieved by meas

of sl :gosd ambulance service, Cases too serious t o be dealt with a t the

level o f brurell health centres could be transported speedily t o -the urban

areas for\ treatment. By means of such a system citi,aens w i l l draw $be b ~ e -

f i t fmw ~e best resources that modern medical science, preventive as well

as curative, can provide,

Staff reqiirements for the rura l health centre have already been menticme&

The simplest rural health centre requires a t l eas t the services of one p'hysi-

cim. Oftenlit has been found tha t two physicians ,are needed i n orden to

acmeve greater efficiency. Furthemnore,~one nurse-midwife and one public

health. nprse, a laboratory technician who can also handle .medical orders and

pmso~LpUons are needed. An auxiliary is usually respon~ible f a r child care.

The centre which i s usually provided with a few maternity beds and-other beds

f o r meculcal and minor surgery (usually ten t o fourteen) serves a s a rule

f i f t een to twenty-five thousand of the population, It should be provided

with stlb*centxes a s de$cribed i n the text; each sub-centre t o serve f ive

thousand, The services i n the sub-cetltres are c a r d e d out by aux i l ia ry per-

sonnel, but i n cer tain countries of the Region medical doctors are employed

i n these sub-centres, . Environmental sani tat ion should be entrusted t o the

sanitarian and health labourer under supervision from the personnel of the

main centre. Education of the ru ra l population as t o how t o construct t h e i r

own latrine&'kd dig t h e i r own wells has been practiced i n cer tain countries

of- t he Region. Technical and f inancia l assistance has been given t o famil ies

undertaking the sani tat ion of t h e i r own homes. Auxiliary personnel w i l l work

under the supervision of the best t ra ined s ta f f of the d i s t r i c t centres who,

a t regular intervals , should male supervisory and t raining v i s i t s t o the ru ra l

health centre. The d i s t r i c t personnel might a t f i r s t provide d i rec t service

i n special f i e l d s such a s tuberculosis, but l a t e r t h i s type of work should be

en t i re ly undertaken by the loca l personnel a f t e r they have at ta ined all-round

public health experience, The l eas t we can accept a s loca l public health

services, are the regis t rat ion and interpretat ion of biological f a c t s con-

cerning bir ths , diseases, and deaths; the control of c o q i c a b l e diseases,

the control of the physical environment through the science of sanitation,

the use of public heal th laboratories, maternal and chi ld health and health

education,

A general survey of the population should precede the organi za'bion of

a l l work. Study of the underlying problems i s the key t o success, or the

road leading to it, Problems such a s endemo-epidemic diseases should receive

the greatest attention. Vaccination against smallpox, immunization against

diphtheria or whooping cough, with evident resu l t s w i l l gain the confidence

of the population, Attention must be par t icu lar ly paid t o the most preva-

l en t endemic diseases, such as bi lharziasis , ankylostomiasis, pa ras i t i c

diseases and trepanomatoses, which constitute the morbidity load of ru ra l

d i s t r i c t s ,

An annual or biannual review of the general demographic indices and

the specif ic indices f o r each disease w i l l prove useful. A study of those

indices, especially those concerning morbidity, w i l l a l so be useful i n helping

. t o determine which medicines the kural health centre should have available f o r

(1) See: ItImproved Tlype of Water-Seal Latrine Slabt' - WHO/E~V, ~an , / l26 , March 1960

carrying out curative services or which of the various preventive campaigns

should receive more attention, A s the situation concerning comrmxnicable &d

enderdc diseases, child mortality and malnutrition improve, problems relating to

mentaJ. health and to.chronic or degenerative diseases begin t o gain i n

importance

Evaluation of rura l projects by experts specialized i n rural health and

social research i s of the greateat importance, Improvement may be imper-

ceptible unless thorough investigations are carried out, Useful but modest

schems may be misjudged, while showy projects may be boosted incorrectly.

Evaluation work conducted on scientif ic l ines w i l l be a guide for further

action i n .t;l~e right direction.

Ths rural physician must rely on the collaboration of each and every

member ,of the communities under h i s care, I f his work i s well executed he

w i l l be a success. I f neglected or only par t ia l ly carried out, it will endanger the entire result of the programme. , , a

. 3

The problems which confront rural health pmjects i n our Region are not

few. One main problem i s financing. It i s the duty of the public health

authorities to prepare the budgets and convince the finance department of the

benefiss, which would be derived thereof, Rural areas are poor and almost

entrlre3y dependent on government funds. It i s often perplexing to the

finance authorities to understand the argument i n favour of curative measures 9 .

i n preventive medicine, Early treatment of disease i s a preventive measum.

C c m t r o l of endemic diseases, such, as bi lhardasis , ankylostomiasis, trachoma,

t~&em$o+s, venereal diseases among others depend largely on treatment cam-

p&.g;ns, Theref ore, the curative-preventive integration should be the basis

onwhich rural health shouldbe soundlyestablished. Financial contributions

to rural health should not be entirely drawn from national funds but financial

assistance from regional, municipal and private enterprise. Attempts should

be sought t o extend compulsory social security to those rural areas where i t

i s deemed advisable, inasmuch as this i s the most promising method f o r financing

medical services. The people themselves should contribute as much as they can.

Payment fo r services received i s being adopted i n certain countries i n this

Region, Its application requires careful acbninistration,

E M / R C ~ ~ ~ 8 page 26

Another problem of profound ef fec t on the services of rura l health i s

the shortage of s ta f f , In the f i r s t place there a re few schools f o r t r a in -

ing doctors, nurses a ~ d a w d l i a r i e s J

The number of s t a f f i n cer tain prbjects i s too l imited t o be able t o

cope with the work eff ic ient ly . Not infrequently, very much needed drugs

f o r control campaigns a re unavailable,

Another impediment i s the lack of physical and recreational faclX.td.es

t o a t t r a c t physicizhs t a work i n rura l heal th centresi This should be reo-

t i f i ed , and actual ly has been taken care of by several countries of the

Region, by provision of sui table housing accommodation f o r the s t a f f ,

It i s necessary t o a s s i s t i so l a t ed ru ra l health centres by providing

them with s t a f f and equipment so as t o ra i se efficiency: t o the l e v e l of the

d i s t r i c t urban centre, Services can also be rendered t o large remote v i l l a -

ges by al locat ing to them the services of auxi l iary personnel, and arranging

visits by the physician once or twice a week, Dispersed settlements require

the services of auxi l iary personnel from the same l o c a l i t i e s whose functions

w i l l not be re la ted exclusively t o public health but w i l l be directed a l s o

toward improving housing, agricultuxe and livestock production, the home, and

toward protecting foodstuffs and giving instruct ions i n t h e i r proper use.

There are appreciable values i n ru ra l l i f e which are recoppized by those

who are endowed with the g i f t of undsrstandingthem. There i s great s a t i s -

fact ion i n rendering services t o those who need help and happiness i n being

respected as me of the leadQrs of the community. Rural l i f e has a charm

which i s indefinable and values found l e s s often i n the tumultuous competitive

l i f e of cit4.e~.

BlBLIOGM,PHY

Irr k ~ r t by the High Council of Combined U n i t s of Egypt. June 1962 - Arabic

2. Firs t Qwr te r ly Report - Octdber Bo December 1 9 5 ~ . Tapei Public Health Teaching Bnd Dennon~trat5.m Ceilte~. Spon80~ed by M Y O ~ Provincial Health ~dministration. Tapei City Govement, Tapei, Taiwan, China.

3. StuQlng your Commity Roldnd L, V a k n Rus s e n Sage, Foundat ion, New Y o F ~ ~ 1955*

4 r Report on Reconstruction ahd h b l i c Sdrvice~, 9952 * 1957. Issued by the Ministry of Municip&li-tf and Ehrlllvai Affairs ; Ambio

5. Fkpqrt of the Permanent Council of Public Services. 4dmznistratiun and Train* Centre of Qalyub, 1954 - 1956. Arabic,

6. Shadows in tbe Sun 3y Stephen Taylor, M.D. M.P, and Phyllis Gcbdsden. korge G, Harrap & Co. Ltd, London.

7. Report of the Ministry of Public Health of the Remblic of Egypt, durhg .the period 19 52-1957. Arab ice

8. Social &ogress through Community Development. &it:ed Nations h r e a u of Social Affairs, New York 1955.

9, Muni'cipal and Rural banlzation by.V.M. ,Ehlers, G.E. and $mest W. Steel, C.E. Mc-Graw-Hill Bo~k Company; Inc .

10, % p e t on Yotable Water in Syria- Publi~hed by. the Ministry of 1 b i c i p a l i t y and Rural ~ f f a b e r . 1961 - Arabic.

E ~ I / ~ c 11/8 ANNEX I page ii

E M / R C 1 1 / 8 ANNEX I1

- I L I i - \ The Rural Health Main Centre to serve Le Centre sanitaire rural principal dessert s &\A, I - t Ilb,,, j j l l 4

30 to 50 thousand, to be aided by 4 to de 30 it 50.000 habitants, aid6 par 4 it

. L-! d~ T iJ.4 &I, 'j6:d?9 6 Sub-centres each serving 5 to 10 6 centres auxiliaires desservant, chacun, thousand. de 5 t~ 10.000 habitants.

1 The main Health Centre

2 Small Hospital, 20 Beds

3 Health Unit Sub-centre

4 Doctor' M. D.

5 Nurse

6 Nurse- Midwife

7 Clinic Room in a Village

Centre sanitaire principal

Petit hi3pital de 20 lits

Centre sanitaire secondaire

MCdecin

Infirmiere

Infirmiere sagefemme

Chambre it usage de clinique dans un village

8 Health Labourer

9 Rural Health Organization

Travailleur sanitaire

Organisation sanitaire rurale

W O R L D H E A L T H O R G A N I Z A T I O N

ORGANISATION MONDIALE

REGIONAL OFFICE FOR THE - BUREAU R ~ G ~ O N A L DE LA EASTERN MEDITERRANEAN M~DITERRANBE ORIENTALE

R E G I O W COMMITTEE FOa THE 'FASTERN MEDITERRANEAN

Eleventh Session

EMB 11/8 .Add. 1. 26 July 1961

ORIGINAL : ENGLXSH

Agenda item 12 (e)

H i st or ical Background of Social and Economic Conditions

I n the Middle East

, Prior t o the dispersion of the Central ~ s i a t i c tr'tbes, i n the pre-Dynastic

period, the liryans who had originated i n the' Iran plateau, had already used

cat t le , horses and sheep and applied the yoke, Similarly, they l o a ~ d t o ' I

plough the land, make certain metal instruments, and build permanent houses.

MarrLage was established m a lawful basis, according t o religious r i t e and

ceremony, The family' liecame the f d a t i o n of the general organizatidn of

the tr ibe, the nation the aggregate of the tribes, and the leader th6"h%ghest

Judge i n peace and the first military loxi i n war, ?Ilk s a d kpplledf t o the

S e d t i c races which constituted the second great ethnic and cul tura l Cn.*sion,

and whose language group bears some structural resemblance t o the Aryan.

These people constituted the Arabs, the Hebrews and those who preceded them

such a$ the Phoenicians who set t led i n the lands which l i e between the Tigris

r iver and the Mediterranean and Red Seas. A branch of these Semites im-

migrated t o East and North Africa and extended the i r domain as f a r as Gibraltar.

The main factor which influenced the development of civi l izat ion i s the

f e r t i l i t y of the plains i r r igated by the rains falling on the mountains which

shield them and the valleys of the r ivers which run through beveral countries

of the Middle East, The R i v e r Nile has endawed Egypt with the g i f t of i t s

ever green valley and enabled men t o establish the most ancient of c iv i l i za t i a?~ .

Man became attached t o t h i s mode of easier l i f e , a f te r striving hard f o r food

and shelter i n pre-historic times. Fields yielded copious craps a d gardens

bore luscious f r u i t s and' beautiful flowers.

I n order t o visualize the economic a d social problems i n the Middle East,

fathom the i r depth and appreciate t he i r magnitude, one must revert first of al l t o Us tory . In studying, for example, the ancient Egypfian civiliaati on or

tha t of plleaopotamia, i n time and space, we are nat 'concerned with medicine but

with people who created medicine a d with countries i n which they lived. The

prevalence of disease i s la rge ly t h e r e su l t of geographic factors. Another

set of such determining fac tors i s t o be sought i n the soc ia l and economic

conditions under which the people l i ve . Civil izat ions have arisen along

great r ive r s such a s the Nile, the Euphrates and t h e Tigris, People l i v i n g

on t h e i r banks and i n t h e i r valleys have become bound by them, almost confined

i n space and subject t o the influence of the floods on t h e i r crops and da i ly

l i f e . Having visualized the4physical environment i n which l i f e i n such

countries unfolded i t s e l f , we must examine the equally important social en-

vironment. Althaugh such conditions must have changed several times i n

history, it is permissible t o discuss such aspects of l i f e i n ancient E m t ,

such a s nutr i t ion, housing, clothing, a s a whole, without specifying wfiich era. I ) (

This study i s interest ing fo r the whole Region, becau~~e of tho 3irKilariity

between Egyptian c iv i l i za t ion i n this f i e l d and other c i v i ~ z a t i d n s i n the

Middle Eastern Region.

Although & s t i n c t changes nave occurred i n the soc.ial l i f e i n several

countrie s, yet we must remmber tha t i n the pre-industrial age l ivfng c o d i -

t ions were much more s t a t i o than they a m today, The Orient i s still i n t h e

pre-industrial age, s o t h a t many techniques, customs, and habi ts have remained

,unchanged f o r thowanda of years.

Mar ria,ge :

Girls : I

East , a l th

t o r u r a l c

m r r i e d a t the age of 1 2 or 13, It i s practised today i n the

ough educated people nuw marry l a t e r . This ear ly mawage presents

omunit ies with overpopulation and increase of urban centres due t o

immigration, a problem of great social and heal th consequences. . Hawevor,

f o r econon@c reasons monogamy was t h o rule i n anciont Egypt as evenwhere i n

the Region,

When a young woman f e l t t he f i r s t pains of labor, she called f o r assis-

tance from a Eow women friends, usually. t w o , She knelt on two oy four

stones o r bricks t o &VQ more room for the del ivery . One of her helpers held

her back while t he other knelt i n f ront ready t o raceive the child. Later a

kind of par tur i t ion chair was constructed, ancestor t o the Kursie el-Wilada

tha t Egypt ian women often use today.

The l o x period of nursing was due t o economic reasons on the one hand,

because the mother's milk was tb cheapest, and simple st food' t o provide f o r

the child and, on the other hand, because nursing prevented conception.

Corutraceptives and abortive r e cipes existed i n ancient Egypt, but were

d h f l n s d Lo very small socis1 groups.

3&pt ian bays were circumcised, The Romans t r i e d t o discourage c i r -

cumclsion but could not suppress it, because cer ta in religious a c t s could be

perfarmed only by o f f i c i a l s who were circumcised, This i s an example of how .< necessary it i s f o r the r u r a l health worker and educat ioml is t t o studiy the

ethqology and h i s t o r i c a l background of customs and habi ts i f he i s t o be

suc ce ssf u1,

Most bf the children were reared Nthout shoes o r clothing because of t h e

mildness of the climate of the country, Herodotus t e l l s u s t h a t i n Egypt

every mah had two garments, loin-cloth ard s h i r t or tunic, and every woman only

one, which was a s l i p t h a t reached from uncler the breas ts t o the ankles, and

wiis hd3.d up by band's w e r t h c i r shoulders. Sandals an3 kerchief f o r women, a

Uneb cap f o r men completed t h e costume, I n modern times, the costume f o r

women has changed i n so f a r a s it has becom loose, and has a bodibe with

sleeves ,

Owing t o the increase i n population (from seven million i n Ancient Egypt

t o twenty-five million at t h e present t i m ) t h e rural population has become

l e s s able t o afford footwear, I n v i l lages of today only the rich wear sardals

or shoes. This 'had influence on the spread of ankylostomiasis. The poopla,

r i ch and poor washed frequent*, rnorning and evening, and before every meal.

The r icher houses had bathrooms. This cleanliness i s s t i l l evident i n r u r a l

areas of Egypt and uther countries of the Middle East. A s the poor in-

habi tants of vi l lages do nut f i n d t h e appropriate f a d l i t f es, they r e so r t t o

the canals f o r bathing and washing t h e i r clothes and u.tensils, Thi8 is a

common sight everywhere in a great many countries of t IB a d d b East. . Instead

of being a useful habit, ft had exposed mill-ions of pe@k t o infec t ion w i t h

endemic diseases, particular'ly. b i lharz ias i s , This hei b i t of washing several

times a day is a firmly rooted habit, orLgLnating from ancismt; h i s t o r i c a l

timos and therefore r equ iws t o be m t 'by reasonable and adequate measures.

It should be one of the ' ma jar considerations i n the programme of rural sani-

ta t ion , I n moiler Egypt, potable water. has been provided t o a largo percentage

of the population, and bathing pools a re being act ively planned fo r fu tu re

construction i n ru ra l v i l lages , The Greek travel-ers were struck by the

Egyptians 1 cleanliness, an3 n d e d t h a t they drank from cups of bronae which

they cleaned dai ly , ani they were especial ly careful always t o wear new*

washed l inen.

The s taple food of the people consisted of bread and beer. Three t o

four loaves of bread andtwo gars of,beer were considered a good da i ly ra t ion ,

Up t o the present, the three loaves are the reccgnized rat ion, The f l o u r

obtained from a kilah (an Egyptian measure) of wheat prcduces one hundred

loaves of bxead, A family consisting of s i x individuals would require bread

worth three E m t i a n pounds each month. This i s the reason -that t h e majority

of ru ra l population a t preserk u t i l i z e maize instead of wheat, because it is

cheaper, Pellagra has been decreasing i n recent years, because Governmerrt s

of the Region provide mom wheat t o t h e i r ru ra l and ur5an population. In

ancient times, i n the Delta, a kind of bread was made from dried lutus . Next

t o bread, f i s h was probably the mst popular food and the chief source of

protein t o the' common people. Rice cul t ivat ion f i e l d s covered with c&or and mar

were and s t i l l a re a p l en t i fu l source of f i s h i n r u r a l areas. A great

var ie ty of b i rds was found along the r ive r a n d i n m r s h e s , Marsheshave

considerably decreased i n recent times due t o the reclamation of land', Cat t le

and sheep ware ra i sed i n the very beginning of Egyptbn history'. It seems

t h a t tho pig was taboo, f o r it was not eaten. Vegetables and f r u i t s were

p lent i fu l , The chief f a t used f o r cooking was olive o i l , and honey was

served for the sweetening of dishes. Nilk was a popular drink, but the most

popular beverage was cagfre beer. The beer drinking has disappeared almost

compZetely and the peasant does not partake of alcohol.

Housing was not very d i f fe rent i n Mesoputamia from what it was in Egypt,

although archi tec tura l s ty l e s var ied, The reed hut was probably the e a r v e s t

dwelling here also, and the clay brick becam the 'chief building material,

The country was very poor i n stone and timber; i n t h e south, stone i s non-

existent. ' Assyria had some quarries from which stone cculd be cut but

bricks were much cheaper and had the additional advantage t h a t they kept the

heat out more effect ively , They couM be hardened i n the sun o r baked i n an

wen, Houses were a s a r u l e b u i l t around a courtyard.there a s i n Egypt.

They had no windows. Light and a i r entered through the doorways, one opening

i n t o the s t r e e t and others leading t o the courtyard. F l a t roofs were very

popular then a s today because the faniily could r e t i r e there a f t e r sunset t o

enjuy the coolness of the night, F la t roofs; however, required. timber, bt. the trunk8 of palm t r e e s covered with clay were good enough f o r the purpose.

Only the very r i ch could afford t o purchase cedar wood imported fran Mount

Lebanon, Houses were roofed with brick vaul ts a t a n ear ly time because palm

t r e e s were not cheap, Granaries and stwe-rooms were vaulted.

,@$h 'an cqening on the top, give more a i r t o a room but do not provide

on Nhich pe ople can sleep. The mansions of the ri ch and the royal

p@Ww, had not only one courtyard but several; they were combinations of

E"rw%@a, There i s no doubt t h a t the block house was developed i n Mesopotamia

aa, Jct wss i n Egypt. The better houses had bathrooms with asphalt f loors and

to$%$ta with water t h a t flushed the night s o i l i n t o t h e s t r ee t . This type crf

houszt, and di sposal is seen today i n Sanata and other towns i n cer tain countries

02 the Niddle East, We never hear of any organized disposal of sewage, but

it i s obvious tha t the farmer used whatever he could get hold of a s manure,

unless he needed the animal dung f o r fue l . T h i s pract ice is followed up t o

the present time i n several countries of the Region, resul t ing in grave heal th

problems, Human dung is the most ser i ous source of pollut ion with grave

infect ious bacteria and parasi tes , Ascaris infection. i s widely spread t o t h e

extent of 90% i n cer ta in areas, F l i e s, such as Musca sorbens and, Muscat v ic iu ia -- f ind su i tab le breeding places i n chwif, This is an e v i l which has persis ted

throughout his tory and theref ore requires, f o r i t s uprooting, bas i c sanitary

re f om,

Furniture, except i n the p l a c e s , was re la t ive ly F r s e and s i ~ l e ,

because such a large pa r t of man's l i f e took place out of doors. Poor people

s l ep t on the f l o o r or on clay bunks along the w a l l , dressed and with a bundle

of clothes as a pillow. Rich people had beds of interlaced cord with p i l e s

of folded sheets a s mattresses and a wooden headrest. Chairs were used from

the f i r s t dynasties on, a f a c t t ha t i s remarkable when we remsmber t h a t mny

or ien ta l p e q k s t i l l squat. lIEvely man has a net with which he catches fish

by day, and f o r the night he s e t s it around t h e bed where he re As, then

creeps under it and so sleeps." Accordin2 t o Herodotus, i f he s l ep t wrapped

i n a garment , o r cloth, t h e gnats b i t through it, but through the net they did

not even t r y a t a l l t o Ixite.

Lm cost sanitary housing i s s t i l l t h e great problem of rura l health.

I n some caurrtries of the Region, research i n s t i t u t e s i n building materials

and designs have been established, The seven per cent cement brick a s sui-

t ab le building material has been introduced a s a subs t i tu te For the clay brick,

and several designs of small houses have been demonstrated i n mcdels, but

plenty of research work i s s t i l l required i n o d e r t o make r e a l prcgress i n

r u r a l health. S ige r i s t states:"We admire the great a r t i s t i c productions of

ancient Egypt, the tombs, the temples, the s ta tues , and obelisks,

We are enchanted with the exquisite work of t h e i r handicrafts, the pot-beries,

the jewels, t h e furni ture , the thousands of bronze statuc t t e s t h e t f i l l our

museums. But we often forget these creations, great and small, are t h e

r e su l t s of tb l c h r of millions of anonymous people, slaves and ser fs and

s&l13 freemen, who to i l ed f o r a bare living, who often sacrificed the i r l i f e

f o r tho employnrsnt of a small upper cia ss."

The labour of the whole region has changed radical ly as compared t o ancient

times. Labour tcday i s respected and i n indus t r i a l areas the workmen a r e f a r

be t t e r off than the agr icu l tura l labourers. T k i r wages, housing corditions,

nutr i t ion, and health a re of a much higher l eve l t h a t t h a t of t h e agr icu l tura l

labourers.

The more one looks i n t o h is tory the more one i s able t o examine and

invest igate the community and plans f o r it s up-levelling and promotion.

WORLD H E A L T H ab b4&l1 ORGANISATION MONDIALE O R G A N I Z A T I O N I DE LA SANTE

&J' REGIONAL OFFICE FOR THE BUREAU ' R~GJONAL DE LA EASTERN MEDITERRANEAN M~DITERRANI~E ORIENTALE

REGIONAL COMMIIllTElE FOR. THE EASTERN r n I T E l x R & w J

. .

Eleventh Session.

EN/RC11/8 .Add ,2 26 July 1961

ORIGINAL t ENGLISH

Agenda i t e m i 2 (a)

RURAL HEA.LTH - ADDEND.W 2.

Community Development i n the United Arab Republic

A. DEMONSWTION AND TRAINING AREA, QALYUB

On March 1952, the World Health Organization and the Government of Egypt

signed an agreement t o establish the Demonstration and Qaining Area i n

Qalyub . The objectives of t he project were:-

1. Planning and coordinating a unified programme f o r health ( the preventive

and curative aspects) for the inhabitants of a dilineated rura l area (Qalyub). r' I

2. Refomng the local administration t o s u i t the socio-ecmom&c: conditions

of the area,

3 Studying means of integration and organization of health semices with

other,semripes i n order t o ra ise the level of the socia-economic conditions

of the area.

4* Evaluation of the unified health service; impact of the health of the

people and i ts influence on the i r socio-economic conditions.

5 , provision of means of training i n ru ra l health i n the f i e l d for 'technical

and specializled officials whether from Egypt or other coui?tries. , .

6 . Advising the Government on the organization of local health administration

and training on i ts application.

The project was granted autonomuu~ adniinistration by the E m t i a n Govern- ment consisting of a board 1*o~rtssuntil!g t h e v 2 r i ~ s m i n i ~ t r i k ? ~ ~rhich Were

interested i n the project,

The scheme of administration is as follows:

Director of the Project

Municipalities \ General Administrator 1 1

Deputy Director

The Board (Headed by a ~ i n i s t e r )

I I

~nspection / revision '\Archives i Stores Personnel \ I t

Projects Cammittee

Finance sec3etarial arid I

Budget Committee

legal matters I I

The Advisory ~ i e i d Committee 1 F'rovinc; Board !

I I Trainin ECO; omic Social Educit ion ~ n g d e e r ing Health Ins t i t u i e Administr . Adminis tr . Adminis tr . Adminis tr . Adminis tr .

Full cooperation with interested ministries and other organizations was

the main and f i r m policy of the centre, and the advisory committees weke

formed for engineering affairs , education affairs , health education, agricultural

and veterinary medicine, f i e ld wcrk and social affairs.

The World Health Organization provided technical assistance comprising nine

advisers i n the f ields of health administration, maternity and child health,

laboratory techniques, epidemiology, sanitary engineering, nursing, v i t a l and

health s t a t i s t i c s and health education,

The Technical Assistance'Boaryl of the United Nations assigma an expert

i n local. g o n m e n t administration. The United States gave assis;t'ance by

agreement t o provide potable water for the area and equipment f u r the Ins t i tu te

f o r training teachers i n health education. The Food and Agrhcultwe

Organization (FAO) concluded an agreement with the Government to:

1. Dig wells t o provide water for i rr igat ion and increase the types of

crops . 2. Train and spread rural industries and training i n the methods of

agriculture.

The stme eganizaticm assigned three experts for t h i s work i n Qalyub: one

agilricul.t;U~e expert; one expert i n home economics and one expert i n rura l

inilwrstzies, UNICEF a lso gave assistance t o the project i n the f i e l d of

' e ~ m i c a b l e eye diseases control and i n the tuberculosis survey, Mareover,

,fourteen fe;llowshipe.were granted by the World Health Organization, Eastern

Neaterranean Regianal 'Of a c e .

The aot iv i t ies and surveys which were carried out i n Qalyub project i n the

period January 1954 t o December 1956 were written i n great de ta i l i n a report

b Arabic of 590 pages. It is a report worth reading by interested speclfalists.

The main task which they faced i n Qalyub was the survey of existing conditions,

A population census had t o be tiaken and for t h i s purpose it was found essential

t o draw maps of the villages, number the houses, and register the families on

special cards. This was followed by a v i t a l and health census, and it was

revealed that half the number of bir ths and deaths were not registered, ' This . 7

fac t made them think of the necessity of appointing a part-time of f ic ia l such

as a teacher i n each village fo r keeping the register of b i r ths and deaths

and recording theon accurately,

Further inves tigatibn's regarding prevalknce of endemic diseases, typhoid

carriers, nutrition&L diseases, dental diseases, were made i n crder t o issess

the morbidity i n the area. Interesting results were obtained. A general

tuberculosis survey was also accomplished. study of the community took

lace' with regard t o rura l industrialization, the vkue of cooperative societies,

cobperative projects, control br cotton worm, insurance of cat t le , examination

of del ' i rqent Ghildren, ccmmunicable eye diseases control, and fundamental ( a

education,

Qalyub area is appra~+nately 250 square kilometres inhabited by a quarter

of a raillion p.opulation. The agreement betwoen the Govwment and the World

Health hganiaation concluded tha t a l l health units i n the area should be

attached t o the oentre. There were four health offices i n the Qalyub dis t r ic t ,

'which were i n charge of preventive work as well as v i t a l s t a t i s t i cs . In the

curative f i e l d there were Qalyub 'hospitals with eighty beds for mescal and

surgical cases and an cut-patient department; Shuhra El Khaema hospital with

forty beds fo r medieal and surgical cases and an out-patient department) an

eye diseases hospital i n Qalyub with twenty beds; an endemic diseases 'hospital;

a leprosy sect ion attached t o Qalyub hospital; one materniw and infant

welfare centre i n Qalyub, and six health centres each s i tua ted in a v i l lage

i n the area. There were three public bathing and washing establishments, each

i n one of three vi l lages. I n addition there were two sections, one f o r the

control of malaria and the other f o r the control of bilharzias. There Wq8 a l s o

one soc ia l centre with a maternity and chi ld welfare u n i t attached t o it.

School health was looked a f t e r by one doctor and three health v i s i to r s . The rp

centre organized i t s health department as follows:

1. Health services comprising maternity and child health, public heal th

nursing, school health, medical supplies.

2. Medical services comprising health un i t s (health centres and health

offices) and hospitals.

3 . Preventive section comprising health education, control of infectious

diseases, laboratories, v i t a l and health s t a t i s t i c s and control of communicable

eye diseases,

I n order t o reach the v i l lager and bring the services near him and arouse

h is i n t e r e s t i n the health services, it became immediately evident t h a t one

la rge centre designed t o serve 15,000 of the population was not suf f ic ien t .

Each v i l lage had t o have i ts own u n i t as a sub-centreto the large health uni t .

A s t he Qalyub project was handicapped by shortage of funds, and it was not

possible t o establ ish these sub-centres, recourse had t o be made t o the coope-

r a t ive soc ie t ies i n the vi l lages. The l a t t e r furnished the s i t e and b u i l t

these sub-centres which became the property of the vil lage. The work was

conducted i n these centres by a s s i s t an t midwives and a s s i s t an t sani tar ians

under the supervision of the doctor and the nurse midwife who staffbd tho ohief

health un i t . The ass i s tan t midlwife car r ies out maternal and chi ld welfare

work, v i s i t i ng f ive families every day f o r health education, hme economics,

and learning the problems and d i f f i c u l t i e s of the family.

The doctor and nurse midwife v i s i t these sub-centres every other day.

The a s s i s t an t san i ta r ian has been t rained not only t o take care of ant i -

malaria and ant i -bi lharziasis work but he has a l so been t rained t o carry out;

1. k q i n a t i o n of houses t o f ind out the s t a t e of drinking water and

drainage.

. Encouraging the peasant t o build a l a t r ine i n his house against a

paymad of one pound t o the cooperative society

3 , ~ n v i t i n g the people t o establish pwnps i n deep 'wells for drinking water.

4. Health education.

The referral hospitals i n (2alyub have been equipped with blood banks,

complete X-ray unit and laboratory; numbers of beds have increased and t o the #

staff have been added special is ts i n the various branches of medicine, surgery,

gynaecology, midwifery, urology, skin and venereal diseases and dentistry.

As mentioned the health services ;ere distributed amokg the

small villages with a central un i t i n one of the big villages, Such an

&ekimekt was carried out i n the vi l lage of Tanan with a population of apprmti-

mately 12,000, S t x other villages were added t o t h i s 'z'one comprising i n a l l

a population of appraximately 40,000, The central uni t i n Tanan compriped:

1, h g l t h section far preventive and curative and an infant welfare maternity , ' unst, 2, section fo r sanitary engineering, 3 , section fo r education, : II

4. social service and rura l industries, 5 , hme economics, 6. agricultural

section, 7. veterinary and a r t i f i c i a l insemination. To t h i s uni t were

xattached a cultivation f i e l d for experiments, public baths and washing stands,

and a mechanical water pumping operation, For every 300 families an assistant

nurse midwife and for every village an assistant sani6arian were provided, I

The t o t a l annual budget for th i s system amounted t o L .E, 12,500.

A special section for health education has takrjn care of th i s act ivi ty

i n Qalyub. Moreover special training courses fo r heads and teachers of

schoals i n health education were carried out i n the centre - school health

had its share. Tuberculosis control and eye diseases control projects

s t i l l cont5nue with assistance from the World Health Organization and UNICEF,

An extensive report on nursing care and maternity and child health has been

made..

Sanitary engineering and environmental sanitation sections have done, a

pee+ &al of work which should have benefited rura l health i n the country i n

general. Social work and education were also treated a t large by the cei tre.

Attempts a t organizing rr~unicipalities were u n t i l recently the responsibi l i ty

of the centre of Qalyub. -Socio-economic work, comprising agr icu l tura l '

guidance and inspection and veterinary medicine has a t t rac ted the in te regt

and part ic ipat ion of the peasants,

The centre has a l so established a t ra ining i n s t i t u t e f o r the vorious

categories of spec ia l i s t s and t h e i r ass i s tan ts and prepared the curriculum I

f o r each category.

It has been d i f f i c u l t t o evaluate precisely the achievements of the

Qalyub project in de ta i l . The work was too extensive t o accomplish s t r ik ing

r e s u l t s and funds were limited. A t first, d i f f i c u l t i e s were met with i n

choosing the s t a f f but l a t e r the project was given autonomy and freedom.

Rural, heal th work i n the Egyptian Province i s advancing,

An agreement was reached i n 195'3 between the 'Government of Egypt, rkpre-

sented by tlie Permanent council for the Development of National Production,

and the United States Operations Mission t o Egypt, for the purpose of improving

economic and soc ia l conditions throughout the country by carrying out a demon-

s t r a t i o n project aiming a t ra ining the standard of r u r a l l i f e i n the province

of Beheira and Fayoum by land reclamation, resettlement, community organization

and development.

The basic objective of the project was t o reclaim new land f o r the provi-

s ion of a be t t e r l i f e f o r a la rge number of landiess families.

The programme cal led the Egyptian-American Rural Improvement Service

(EARLS) included the following :

1. Reclamation and cul t ivat ion of about 80,000 feddans of new land i n

the Beheira and Fayown provinces.

2. Building the necessary houses and public services f o r the populadion.

3. Resettlement of about 16,000 tenant families i n reclaimed land.

4. Cooperation with responsible organizations fo r :

(a) Vocational t ra in ing and the t ra in ing of rura l youth according

t o environmental conditions on sc i en t i f i c methods of agricul ture and modern

b r i g a t i o n .

(b) Providing means of agricultural guidance.

(c) Working towards improving, marketing and industrializing

agricultural products,

, (d) hproving the general standard of health by providing a healthy

environment and medical services with health education and training,

( 0 ) Aid i n developing small industries and hand crafts.

( f) Developing cokuni t ies i n which people administer the i r awn affairs . . > .

5 , Improving and developing' the network of roads t o f ac i l i t a t e means of

transport and communication between the f a m and the market,

The aim was t o develop and create an improved rural community and t o t ra in

t he new residents t o the point where they could administer thei r own community.

It was expected that the pattern developed by EU2IS could be applied i n other

areas of ,Egypt.

EARIS .experts i n socia2 welfare, health, education and agricultural

extensionpromoted social improvement i n village cmnunities,

I n F a p province EARIS selected 6,000 feddans i n Qoota area south of

Lake I k m m and 7,000 fedwns i n .the Kom Oshim area north-east ,of the lake a f te r

s o i l research proved them to be best suited fo r reclamation.

I n Beheira prqvince, the Abis area, composed of approximately 24,000' $6

feddans i n Markaz Kafr e l Dawar, has been selected, The area l i e s t o the

sazth-east of Alexandria and i s bordered on the north, scvuth an4 eas t by

agricultural land. Since a greater part of the Abis area was formerly paPt

of the Maryut Lake, which i s the uutlet for a l l drainage canals i n the Beheira

province, th'e s a l t contents of the s o i l are high. A great deal of ef for t i s

%herefore required for de-salting and reclaiming the area for agricultural

purposes. FARIS have established a vast network or irr igat ion and drainage

canals fo r modern and varied agricultural operations,

Cropping of leached lands is undertaken by trying scme sal t - res is t ing

plants : rice, barley or berseem, Soi l analysis and observation of the growth

of the various crops continue as measures of the reclamation and development

Y? See map an f o l l d n g page

progress * Once such progress i s assured other more valuable crops, l i k e

cotton, wheat, beans and corn, a re t r ied .

Master plans f o r the layout of the area include dust-proof roads, other

public u t i l i t i e s , a network of potable piped water supply And the importance

of e l e c t r i c i t y i n rais ing the standard af l iv ing i n r u r a l communities is not

overlooked.

Qcellent schools have been b u i l t and a programme of adult and vocational

education provided, A soc ia l centre building and a health c l in i c i s provided

i n each v i l lage and a larger, well-;quipped hospital with in-patient accorhmo-

dation i s central ly located i n the area,

The one-storey house consists of a l i v ing roam, two bedrooms, bathroom,

kitchen equipped with an oven, a storeroom and a s tab le f o r the animals, It

a l s o ha9.a courtyard. The house i s so planned tha t the s tab le has a separate

entrance. The two-storey houses have a s i t t i n g room, bathrbam, kitchen with

an oven, and a storeroam on the first f loor and a s ta i rcase leading t o two bed-

rooms with a la rge balcony on the second f loor . Attached t o the house i s a

s t ab le f o r t h e animals with a separate entrance,

The t o t a l cost of the house is about L.E. 300.

Every hous; has a new oven, economical i n f u e l consumption and equipped

with a spark arreetcr .to prevent dangerous v i l l age . f i r e s , This type of oven

was developed a f t e r intensive research and proved t o be sui table for r u r a l

cammnnities. It can be considered a fur ther s tep toward a be t t e r l i f e f o r

the Egyptian farmer.

In select ing s e t t l e r s i n the vi l lages a select ion committee of EARIS

decided t h a t one-sixth of the lands would be dis t r ibuted t o people',who worked

on the project, another s ix th would be d is t r ibuted t o landless f'armera from

the suburbs of Qexandria, and the other two-thirds would be dis t r ibuted t o

landless , farmers selecbed from t e n adjacent over-crowded vi l lages in Beheira

province . These s e t t l e r s had t o be inhabitants of the designated v i l lages and t o

have wo$ked i n agricul ture f o r a t l e a s t two years. Preference was given t o

farmers with longer experience. The s e t t l e r and h is family had t o be land-

l e s s and not expected t o inhe r i t aqr land. Persons infected with tuberculosis

or leprosy were excludgd as a measure of protection t o the res t of the new

communily. The age of the family head was s e t a t between 25 and 45 years.

The maximum size of the fwnily was s e t a t s ix persons with a t l e a s t a thljld ! , ,

working hand. Large families would crowd the house and increase social and

sanitary probl ams . During the f i r s t yew the s e t t l e r i s a tenant, l iving in the village gn

probation, A t the : end of the f i r s t year, he may be el igible for a purchase

contract. p~ \ se t t l e r has the r ight t o s e l l the land a f t e r eight,years of

asnership, provided he has met his commitments and the buyer.is qualified,

Land is distributed only a f te r making sure tha t the incame.from its

crops w i l l not only meet the requirements for a proper l i f e , but w i l l a lso

provide additional money for the se t t l e r . The average yield of the land

now being distributed by &IS i s 3 kantars of unginned cotton, 9 ardaba of

r i c e and 6 ardabs of maize. After the first six years, ordinary crop output

is expected t o increase. Such an increase w i l l cane from raising cat t le ,

poultry and vegetable crops. his increased income w i l l erkble the f h e r a a .

I ' 1 .

t o meet his financial obligations.

Each s e t t l e r is given a grant of L.E, 5 , during the .first sj;x.months

of his l i f e in the village t o enable him t o buy necessary supplies The

Agricultural and Cooperative Bank w i l l provide loans for the purchase of

necessary seeds and f e r t i l i z e r s according t o usual conditions and regulatjons,

The village cooperative society w i l l lend the s e t t l e r as mch as Lo$. 65 t o

buy a buffalo and l i gh t agricultural equipment. The money i s t o be repaid

within six years with EARIS as 'a co-signer of the note.

Meed ex is t s fo r a period of training i n which ,the se t t l e r s can learn the

techniques of modeyn agriculture and the up-to-date way of increasing and ,im-

proving production, Agricultural extension workers are available t o advise

the'!settlers on the best agricultural practices and t o teach dairying, poultry

raising and other farming sk i l l s ,

A modem system of village administrrltion is beirig introduced by EARIS:

village affa i rs are t o be handled i n i t i a l l y by a cuuncil consisting of

special is ts i n social and agricultural a f f abs , the school headmaster, a

physician, an agricultural extension worker and certain residents of %he village.

E?bf/R~llr8 ,Add. 2 page 10

They cooperate i n considering the a f f a i r s of the v i l lage and in working out

solutions t o problems, Later t h i s council w i l l consist solely of: vzllagers

ak%er they have gained experience i n managing v i l lage a f f a i r s and solving t h e i r

c-ity problems . Important among the duties of the council i s t o assure the maintenance of

the public buildings and the homes of the residents and t o provide the public

services necessary .t;o create a community envjxonment sui table for developing

good ci t izens. 'The cuuncil w i l l be concerned with other a c t i v i t i e s i n the

f i e l d s of pgriculture, health, cu l tura l and soc ia l a f f a i r s and camm.unity

development.

C, COMMUNITY DEVELOPMENT I N TE-FE PROVINCE OF SYRIA

As mentioned i n the main paper on Rural ~eal thi ' , the t e n y e a r national

programme f& se t t ing up 110 projects, including seven zones of the Syrian

region, has been accepted i n principle, and inclGded i n the five-year plan.

Haran El Awamid, one of the eight p i l o t projects f o r which funds are already

avajlable and which a r e expected t o cover a population of over 200,000 i n eight

nahias, has been i n operation fo r wer two years (s ince 1959) and the two a t

Salkhad and Sheria, over four months, The buildings for the four th p i l o t

project, .Jobet Burghal, are nearing completion and the project i s expected t o

be launched i n July 1961, The buildings for the f i f t h p i l o t project, Kafferine,

a re under constmction. The buildings f o r three projects, a t Sheddadeh,

Mayadin, . and i n Abu Nureere, w i l l be constructed during 1961-1962.

Ten multi-purpose v i l lage l eve l workers, graduates of agr icu l tura l secondary

schools with six months supplementary t raining i n pract ical agriculture, coope-

ra t ives , r u r a l health, rudimentary c i v i l engineering and prirlciples and methods

of community development have been provided i n each project. Each vi l lage

l e v e l workers a re guided, supervised, and controlled by seven subject matter

spec ia l i s t s i n : (1) agriculture, ( 2) animal husbandry and veterinary, (3 ) public health and medical aid, (4) cooperatives, (5) soc ia l education,

(6) home economics, and ( 7 ) c i v i l works. There is a common director of the

project t o coordinate the en t i r e programme. One project area covers a

population of 25,000 t o 40,000,

* See: EN/RC11/8

E M 4 ~ ~ 1 1 8 Add r2 page 11

The ,necessary institutions, such as a dispensary with maternity and

child w ~ l f a r e centre, a veterinary dispensary with an a r t i f i c i a l insemination

subAcen-bre, a p w t r y uni21, a nursery, a central l ibrary and an infopnation

centrq with 'a cinefilm-bus, are provided a t the project headquarters.

. . Each project costs about L.S . 300,000 t o 400,000 for buildings,

(L$, 3.57 = $ 1) water supply and electr ici ty, L .S . 80,000 for equipment,

fu rn i twe and t r a ~ s p o r t , L,S, 110,000 per xmm fqr balaricsts and allowances

fo r staff , LS, 50,000 for recurring contingencies, and L,S. 25,000- for

grants-in-aid. In addition, short-term loans i n the amount of L.S. 150,000

are provided by the Agricultural Bank, The t o t a l estimated expenditure over

the e n t b e t snqea r period i a L.S . 72.18 million. The over-head cost for

*the training of s ta f f i n the Department of Cammunity Development a t the State

headquarters, has not been included i n the former estimate.

Significant results have been'achieved i n increasing agricultyral pro-

dilction through the use of improved seeds and chemical fer t i l izers . Wheat . .

(rahge of increase between 62 .l% and 106.55 i n demonstration plots i n 1959-

1960) cotton, vegetables have been favourably affected, cotton pests have

been 6ont2olled, prophylactic inoc&tion of sheep, goats and ~ o u l & against

epidemic diseases has been undertaken. Distribution of improved seedlings

and plants has helped t o popularize horticulture. Medical and maternSaby and , 8

child welfare services have been promoted through the health units. Veterinary

aid has been given, cooperative societies organized and operated, Home econo-

mics, l ibrary services, a nursery for young children, training courses and study

tours fop farmers have been established as well as a cinema t o i l l u s t r a t e aspects

Of social education and self-help.

Two sk-month courses for training village level wtrrkers i n 'the principles

and methods of community development, cooperatives, rudiment$ of ru ra l health,

some aspec& of ctivil engineering, and practical agriculture and animal

husbandry, have been organized and these are i n progress.

Inter-agency collaboration: The IrJ:iO experts on sanitary engineering,

maternity and child welfare and rura l sanitation, FA0 special is ts . in agricultural

s t a t i s t i c s , a r t i f i c i a l insemination, and fisheries, and experts i n cooperatives

from ILO, have been closely collaborating i n th i s on an W o x m a I

personal basis.

m/acx1'/8 .Add i 2 page 1 2

This information has been obtained from a mimeographed note prepared f o r

an informal community development group i n the Syrian Province, UAR which

has been advising the project s t a f f , par t ic ipat ing i n the t ra in ing of the

projeck s t a f f and i n sw cases the vi l lagers , and consulting with the expert

on cammwnity development. 1

, . * " The ru ra l health s i tua t ion should undergo evaluation t o assess present

conditions and d i rec t fu tcre blans. I n 1934 Stkar t G. Doddpublished an

in teres t ing book bn a controlled .Experiment on Rural IIygieneG i n syr ia . He

made a comparison between the outstanding unhygienic features of r u r a l l i f e

with tha t of the urban, sample. The differences as given by the author of

t h a t book a re s t r iking. To quote only t h e ' f i r s t of fo r ty items mentioned:

it was s ta ted t h a t while the nearest doctor fo r r u r a l people was a half day's jour-

ney ;?;lmy, and he'wns usunlly one of s,?cond-rate t ra in ing , i n the qur?.rter of the c i t

where he was l iving, excellent hospitals, f ree cl inics , a health centre, and

a medical. school were located. An experiment was conducted t o f ind out the

influence of these different factors on hygienic conditions . ~ i i n i c s were

held by the doctor once a month, follow-up c l in i c s by the nurse once a week or

oftener a s well as home treatments f o r s ick people, monthly home v i s i t s f o r

instruct ion and inspection of a nursery school ( f r e e for a l l children), clubs

and weekly classes fo r mothers, clubs and weekly cl&sses f o r g i r l s and public

lantern-slide lec tures ,

Demonstrations were a l so performed such as washing the eyes of the people

i n one whole v i l lage i n the spring t o emphasize eye hygiene, i n s t a l l i n g model

l a t r ines , planting eucalyptus t rees t o drain marshy t rac ts , improving the well

or spring t o demonstrate a sani ta t ion project, draining small l o c a l mosquito

breeding areas, etc.. The c l in i c lacked materials f o r v isua l education adapted

t o l o c a l needs. It has been s ta ted t h a t the problem of a r u r a l health service

cannot be solved by such a c l in i c because i t ' i s too expensive f o r the l o c a l i t y

t o support, but it may go f a r toward solving the problem i f it can be .developed

t a a greater extent as a t ra ining centre fo r v i l lage women and as a place

where national supervisors can be educated, During the two-year period,

economic income was d i s t inc t ly shrinking throughout the area. The r a i n f a l l

was usually small. Insofar, then, as hygiene is an ef fec t of wealth (in

the in te rac t ion of the two), the decrease of the wealth fac tor would tend t o

E%l/'R~11/8 .Add .2 page' 1 2

lower the hygienic status. Accordingly, Dodd concludes that the c l in ic then " / I *

emerges frcln th i s analysis as the chief agency which generated the hygienic

forces which caused a progress of 2% t o 65% i n the hygienic status of the

~ ~ i a n ' v i l l a g e s i n h i s stu4v. ' The methods follawed i n these studies are

elaborate and could be consulted as a reference. It should be emphasized

here t h a t .evaluation methods are extremely important especially i n th i s . f i e ld of public health because error here may often result i n condemning

a usehzl project or praising an unsatisfactory expensive one. " >

Mare recently i n 1958, the World SIealth Organization, Regional Urrlce

for the Eastern ~editerraneak,entered the f i e ld of rural health i n the

Province of Syria, UAR. 1

The objectives of this project were:

1. To a s s i s t the Government t o develop and carry out a national plan for

the improvement of environmental sanitation, particularly i n rura l areas and

i n the smaller towns, including ample, convenient and safe potable water

supplies, hygienic methods of human excreta disposal, the control of insects

and other vectors of disease, promotion of refuse disposal and village or'

town cleanliness, food sanitation and other appropriate aspects of rural

environmental sanitatioa. Through such means it is hoped t o prmote health

and prevent disease, pax-titularly those diseases constituting a principal

cause of infant and child mor%olity, enteric anddiarrhoea1 diseqse, insect

or other vector-borne diseases, communicable eye diseases and others having

the i r origin or transmission,,through the environment*

2. To give support t o tho national malaria eradication projects particuiarly

i n rura l areas. 3 8

3 . To provide f i e l d training opportunities i n environmental sani tation for

sanitarians and other health personnel. The project entailed the development ,

of a national programme for environmental sanitation with particular reference

t o ru ra l areas and small municipalities, and the execution of such a programme

under the administrative and technical direction of the Ministry of: Health.

i$oreover, another WHO project was ,aimed a t es tab l i~h ing a rural health uni t

t o serve thir teen villages i n the area of the Eastern Ghouta, which consists ' ' . \

of an axtensive green plain, around' ~amsscus c i ty . A t Sakba, a two-;torey

house had been rented as the s i t e of the rura l health centre, the objectives

E M / R c ~ L / ~ .Add ,2 page 14

of the ru ra l health demonstration and, Graining project wePe:

1. To develop i n one nahya (sub-dis tr ic t ) existing heslth services i n t o

a p i l o t sys tem of integrated (preventive and curative) health services

functioning a t the nahya level . I

2. To develop concurrently t h i s sys tern of administration fo r these services . 3 . Ts,expand and integrate these serviaes d t h those of the d i s t r i c t and

province and of the cent ra l administraC$n~,

4 , To establ ish i n connexion with 1, and 2 . above, a ru ra l health demons t ra -

t i o n and t ra in ing centre fo r various categories of health personnel.

5 , To provide f a c i l i t i e s f o r tes t ing and proving administrative and technical

p r o c e d u r e s i ~ i t h a view t o t h e i r introduction and adoption il? other nahyas (sub-

d i s t r i c t s ) of Syria ,

6 . To a s s i s t i n the reorganizgtion of a small number of nahya and d i s t r i c t

(Khada) health services i n provinces ~ t h e r than Damascus.

7 . To par t ic ipa te in the balanced economic and soc ia l development of the . .

country by co-ordination wherever possible of the e2tended hbalth services

with other phases of such development.

Among the many facets of project ac t iv i t i e s , a l l correlated t o each, other, . ,

one m y c i t e the increased knowledge of the project area concerning both ra te ,

in fant mortali ty diseases, health and soc ia l conditions. An introduction was

made of t h e idea of integrated health services, health education, communicable

diseases control such as case-findings, smallpox and BCG vaccination, maternal

8nd chi ld heal th work, laboratory, l imited t o simple routine examinations;

curative care, dispensary with pharmacy, e t c . A sub-centre was a l so established

a;t Gerernana.

A s regards t ra inink of health personnel there was s ta r ted :

(1) The daya course with eighteen old dayas and young re l a t ives of the

oldc23;yc~s;this was very succesdf'ul

(2) A refresher course t o nurse a9.A~ and health v i s i t o r s (continuing)

( 3 ) kbora to ry technician aid course (continuing)

*EN/&c1~/8 .Add .2 page 15

(4). Planning of a r u r a l midwife a id c.ourse

&on& th' health workers be t t e r understanding of public health was achieved,

the' Sakba Centre, Geiyana sub-centre and the mobile dispensary t o Beid Sawa

earpknded t h e semices. k second medical off icer ' was appointed. Thrazgh

ma4kh1' and chfld health ao t iv i t i e s , the daya course, the dispensary, c l in ic ,

health cawdttees and health bducation programmes, 'h&e v i s i t s " and d f r i c i a l

discussibns, the pro3 ec t made government o f f i c i a l s and the population' aware

of the idea t h a t the promotion of health is something tha t is not only the

task of the Ministry of Health but the responsibi l i ty of individuals, families

and communities themselves. However, the cammunity continued t o ask f o r more

medical off icers , more medicines f o r the sick. A good sign was t h a t t he

health c a m i t t e e of Sakba requested a lso a garbage disposal programme. The

r u r a l heal th demonstration and t ra in ing project provided a prac t ica l set-up

f o r heal th demonstration indispensable t o the development of the community.

On the other hand the project demonstrated t h a t r u r a l health wmk was impossi-

b l e i f the workers i n t h e ' f i a l d did not receive some allowance to cowensate

f o r hwdships . It was recammended t o study the poss ib i l i ty of t ransferr ing the t ra in ing

programme t o Haran Al Awamid, as mentioned previously, where the Ministry of

Social Affairs, directorate of Community development, constructed a huge

complex of buildings. The United Nations Adviser t o t h i s project s t a t ed

t h a t t he re was ample roan for a l l the planned training a c t i v i t i e s including

a maternal c l i n i c with twelve beds.

It has been recommended tha t should the negotiations with the m n i s t r y

of Social Affairs give a negative resu l t , the t ra in ing project should be

t ransferred t o an area representative of the ru ra l areas of Syria. A plan

should be drawn up f o r the phases i n which rural health centres would be die-

t r ibu ted over the Syrian Province f o r the next ten or f i f t e e n years. It

would nut be possible t o s t a r t with centros i f there were no personnel avail-

ab le but, on the other hand, it would be bad policy t o t r a i n health workers

and leave them wiChmt employment a f t e r training. The country, a t the time , ,

of writjng,was i n need of a t l e a s t 1x0 m a 1 health centres.

E N / R C I , ~ / ~ . ~ d d 3 page 16

After ten years approximately 130 t o 150 r u r a l health uni ts were expected t o S t

.be necessary t o cover the whole Syrian Province (Niemer) . For the near

future it would be advisable t a consider a l l the planned maternal and child

health un i t s and sub-centres i n the Syrian Province as a nucleus for rural

health uni t s or centrps and t o make budgetary, ,psovisions accprdingly $px, 1960 t o 1961. Transfer ?f the responsibili ty of school health f r m the

Ministry of Education t o MimSstry of Health would be advisable fox administra-

t ive and pract ical reasons.

36 See : E M / P H A / ~ ' ~ - June 1960.

WORLD H E A L T H ilb i/'i4/'1 ORGANISATION MONDIALE O R G A N I Z A T I O N DE LA SANTE

REGIONAL OFFICE FOR THE BUREAU R~GIONAL DE LA

EASTERN MEDITERRANEAN MBDITERRANBE ORIENTALE

REGLONi& ColfMITTlSb FUfl 'l'u EASTERN m1-

Eleventh Session

Agenda item 12 (e)

EN/RC11/8 ,Add r3 26 July 1961

ORIGL1lAL : ENGLISH

RURAL HEALTH - ADDENDUM '3.

Though only eight years have elapsed since the s t a r t of public health

act iv i t ies i n Iran, cuuntrywj.de achievements have been considerable and health

conditions are improving steadily. A t present most of the people realiz6 the

importance of sanitation and observe i t s principles.

It is hoped tha t with the devoted efforts of our sanitary engineers and

special is ts further success w i l l be achieved i n future.

One ,of the important branches of the General Department of Sanitary

Engineering is the Environmental Sanitation branch which plays a significant

ro le i n raising health standards of the rura l population through acquainting

them with health measures, and municipal population thruugh technical assistance

and sugenrision. Considerable progress has been made since the shr t of t h i s

Rural health act iv i t ies i n Iran before 1950 were limited ,to .:mLijl3.%a control

which was conducted .only i n selected areas. Contaminated water supplies plwed

a significant ro le i n the spread of water-borne diseases such as typhoid qnd

dysenteries, Organized health act iv i t ies started f i r s t in the m a 1 areas.

Although the progress bas very slow due t o general ignorance .and l ~ k of

appreciation of the value of the services rendered, nevertheless the efforts

of our health workers gradually broke thraugh the barrier of public ignorance

and superstition. The cooperation and financial contribution by rura l popula-

t ion a t the beginning of the programme were negligible whereas a t present

75 per cent of project expenses are met locally,

I n m a 1 areas the General Depa~tment of Sanitary Engineering s t a r t ed basic

environmentalsmxL.tatian a c t i v i t i e s such as construction and ins t a l l a t ion of

sani tary l a t r iqes , improvement of water supplies, construction of water reservoirs

and d is t r ibut ion systems, v i l l age clean-up campaigns, garbage disposal, methods

f o r f l y control, and f ina l ly conducting heal th education programme by meavs of

lectures , and educational motion pictures. After a few years, other heal th

a c t i v i t i e s were added t o the above programme namely, construction of sani tary

public bath-houses , slaughter houses, mortuaries , improvement of ru ra l dwellings

and controll ing food establishments,

Another effective sani ta t ion ac t iv i ty which s t a r t ed recently has been the

guinea-worn control programme i n the south p a r t of I ran, I n t h i s programme a

t o t a l of 245 "Berkehtl which a re the main suurce of the disease, have been sani-

ta ry improved.

Act iv i t ies i n urban areas s t a r t ed with the most effect ive programme of

Itci'by water supplies1I. I n order t o prepare potable and ample water with the

l e a s t cost and minimize technical supervision and equipment, a long range deep

well programme was planned f o r d i f fe rent c i t i e s of Iran. 79 deep wells were

dug during a period of f ive years, beginning a t 1951, out of which 4.6 were dug

by the General Department of Sanitary Engineering and 33 under USCM programme,

Since t h a t day 33 p a r t i a l d i s t r ibut ion systems have been completed in di f fe rent

c i t i e s of Iran. These systems which consis t of a main pipe and several public

water stands have been ins t a l l ed according t o the general design and can be

a t e n d e d i n future with t he g r ~ t h o f population and f inancia l a b i l i t y of re la ted

municipalities.

Since t h e beginning of the activities of pXan mganiaation which has been

established f o r c m u n i t y development and improvement of Living standards, marry

projects have been prepared f o r new water supplies as w e l l as extension of those

33 sy;roteons.

Other a c t i v i t i e s i n t h i s category have been mainly s a n i t q inspection of

public ~ l a c e s . To f u l f i l such a c t i v i t i e s t h i s Department is now working on

preparation of t h e necessary codes and regulations,

Establishment of a Sani tat ion School t o t r a i n sanitarian-aids has been one

of the highlights of the programme. Candidates for t h i s school are selected

from rural areas and municipalities, and a f t e r being t rained f o r nine months,

undergoing basic sanitation courses, they return to thei r areas fo r service.

A t o t a l of 374 sanitasian-aid$ have graduated during the past seven years

including 16 students fram Lf $ ~ r & k n .

A very u s e w training programme which star.t;ed recently has been "water

operators courset1 , Candidates for t h i s course are selected from municipalitie:

and af te r being trained for a period of two months will return t o t he i r c i t i e s

t o operate the systems which w i l l be completed and handed over t o the rrmnici-

pa l i t i e s . Another step i n connexion with training has been the training abroad of

the local engineers i n the f ie lds of sanitary engineering and environmental

sanitation,

Consequently today, only eight years a f te r in i t i a t ion of the act iv i t ies ,

people, especially the young generation, have developed a firm belief i n health

principles.

The summary of ac t iv i t i es in m a 1 and municipal sanitation programme for

the past eight years is as follows :

A - Rural Sanitation:

1. h b e r of shallow wells dug and hand pumps instal led

2. Number of privies constructed

3. Number of sewage systems constructed

4. Number of water distribution systems completed

5. Number of Berkehs improved

B - Municipal Sanitation:

1. Number of deep wells constructed

2. Number of water distribution systems canpleted

C - Training:

1, Number of sanitarian--aids trained

2, Nwnber of water-works operators -txtlined

WORLD H E A L T H i.bld14.,4~ +I ORGAN ISATION MONDI ALE O R G A N I Z A T I O N

&;I If ,,+ &I DE LA SANTE

. REGIONAL OFFICE FOR THE - BUREAU REGIONAL DE LA EASTERN MEDITERRANEAN MBDITERRANBE ORIENTALE'

REGIONAL COWITTE3E FOR THE U T E R N MEDI-

Eleventh ~ e s s ion

lM/~~11/8 .Add .4 26 July 1961

ORIGINAL: ENGLISH

Agenda item 1 2 ( e)

WRkZ HEALTH - ADDENDUM k .

Trachoma and Tuberculosis

DIS~IBUTIO~~T Aim YXEYALENCE OF TLVICHOYLA GIVEN IN PERCEDJTAGB IN E-IE COUNTRIES OF THE REGIOijI

Following is the information available a t the Regional Office on the

prevalence of trachoma i n the Region.

Elhiop'ia proper - Some dlata are available fram surveys carried out by Doctor:

~ d u f e r ( ~ ) and Delon!') Active trach- cases among school children i n Addis

Ababa 36 .k% - i n Gondar 50.1% - & Harrar ' 4 4 . ~ .

Eritrea - The prevalence of trachoma has been recently decreasing as a

resul t of the control ac t iv i t ies carried out for some yews, The most highly

infected area is the central mountainous par t of the country. ( h z i e n ) with

a prevalence of about '75% - 8C$ of active cases. , A marked decrease was

observed i n the 'division of Acchele Guzai from 97.2% t o 51.8% i c t ive cases;

in. the fled Sea division fran 71.7% t o 29 .C%; i n Keren Naqfa from 97.3% t o 38.5%

(according t o Professor Guerra, Chief, Haile Seladsie I Hospital, Asmara) . Iran - Caspian sea coast t o t a l trachoma 41.7% thereof active 13.4%. -

Central area '49.6% thereof act'ive 19.3%. ' On the ~ e r s i a n Gulf coast 73 .% thereof active 38.6%. Thd prevalence of trachoma is higher i n the kural

areas, Trachama occurs i n early childhood bu.t has a tendency t o rapid healing.

IGaq - Prevalence of trachoma ra tes recently detected by D r . Uufer are

less than the rates given by Dr. Tabcne i n 1956.(3) Prevalence rates of total

trachoma vary between 35.3% i n Kirkuk liwa and 83.2% i n Dulaimaniyal liwa

( according t o D r . Tabone) . EM/TR.AcH/~J - February 1961

( *)EM/TRACH/~~ - November 1959

(3) EN/TRACH/~ - February 1956

E I % / R C ~ ~ / ~ Add .4 page 2

D r . C'ufer found i n Basra 55% trachomatous cases of ,whick 32% were active.

I n iVIosul 59.6% t o t a l trachoma of which 31.7% were act ive, Prevalence r a t e s

i n saghdad a r e estimated t o be around S @ .

No def in i te information i s available on the difference of prevalence

r a t e s between r u r a l and urban population, but very l i k e l y trachoma i s more

prevalent i n the r u r a l population.

Jordan - Prevalence ra tes of ac t ive trachoma i n the r u r a l population a r e ' -

44.4% i n Hebron area. Similar ra tes a lso apply t o the ru ra l areas of Jerusalem,

Nablus and Karak d i s t r i c t s . Prevalence r a t e s i n the c i t i e s a re lower ( i n

Hebron town 31.3% ac t ive cases), .in h a n town, however, 12% of act ive cases were

only found among the school population.

Kuwait - Prevalence of t rachma is re la t ive ly widespread: 9% with about - 5% act ive cases i n the school population. I n Kuwait town the prevalence of

trachoma is very mild, but moderate or even severe i n r-emote areas.

Lebanon - No recent data available. Trachoma w a s reported t o be more

prevalent i n the southern hark of the country, however, trach&a is not consi-

dered a public health problem i n the other par t s of the country.

Libya - ?rachoma is highly prevalent and ranges between 9@-10% i n the

r u r a l population. The prevalence of trachoma i n Tripol i i s reported t o be

around 3.5%. I n general t&achoma i s very severk i n Libya.

Pakistan - I n East Pakistan trachoma is no public health problem with

oriLy 1% of ac t ive cases.

I n West Pakistan the following percentage r a t e s a re reported, North-West

f ron t i e r 7s thereof 43% active; Sind 57% thereof 35% active; ~ a l u c h i s t a n 57% thereof 3@ active; Karachi 25% t o t a l trachoma.

Saudi-Arabia - A high prevalence of trachoma i n general. In the dastern

region i n 1956, more than 9% of the chi ld populatiop had t r a c h ~ a .

From experience i n the western region (~eddah) almost every pat ient seen

had t r a c h ' w .

Sudan - A recent survey by D r . elo on") shared an okerall prevalence of - trachoma i n most provinces (below ~ % ) h & e v e r , i n the northern province a

prevalence of 46%. The highest prevalence of trachoma was found close t o the

( 4 ) ~ e p o r t t o be published i n E~~/TH.AcH/- se r i e s by EMEiO i n September 1961.

Egypt3.afi border, where the ru ra l populations of Wadi Halfa and Merme had 56% uf actitte3 trachoma, Active trachoma was most prevalent among school children,

namely 76 of children i n Wadi Half a and 8 6 of chil&en i n Merowe . I n urban

areas h$gh prevalence of trachoma was f mnd i n Atbara town with 25% ( children

5% of act ive cases),

Tunisia - Trachma was prevalent between 90$-10@ in the t o t a l population

especially i n ru ra l areas i n the south. Trachuina control a c t i v i t i e s have been

carr ied out aver a few years, huwever, recent figures on prevalence ra t e s a f t e r

the campaigns a r e not available.

United ~ e ~ u b l i c (Egypt) - There is a high prevalence of trachoma i n

the r u r a l popiilation ranging between 9@-10%. A lower prevalence of trachoma

exis t s i n the urban population but no data a re available,

United Arab Republic (Syria) - A low prevalence of trachoma is estimated

(note more than 15% a l l over the c d n t r y ) , but localized t o ?ertain d i s t r i c t s

where the percentage i s much higher, especially i n the south. The &$ease

appears t o be decreasing with the hprovment of l i v ing conditions,

Yemen - High prevalence of trachoma up t o 10% i n the school population .- i s reported.

From general experience it has been noted t h a t trachoma decreases with the

improvement of l iv ing conditions and tha t it is more prevalent among the r u r a l

population.

Blindness i n the countries of the Region - The incidence 01- t u m ~ ~ + i n d -

ness i q most of the countries of the Region varies from 0.3% t o 1.0% of the ,

t o t a l , populatipn, Blindness i.n one eye may be estimated a t the utmost 2.G

of the tcrtal population i n same countries of the Region. The most common

reas on f .or blindness is considered. t o be seasonal ophthalmia, responsible for

more than 8% of cases of blindness. Not more than 1% of a l l blind cases

a re estimated t o be caused by trachoma.

B e CQ,.P~L~LATIVE PREVALmCE OF TUBXICULOS IS WITK S PECIAL ;<EFEURTCE TO D3BAN AND RURA'I, AFtEAS

t

With the present-day. epidmiological trends it is ra ther d i f f i c u l t t o

generalize, a s was done i n the past, t ha t there is considerably more tuberculosis

i n c i t i e s and urban communities than i n the ru ra l areas. While survey resul t s ,

such as those s h m i n attached tab le give some re l i ab le ovei4all prevalence

i z l d i ~ s t ~ o n s , it i s from the analysis of s t r a t i f i e d groups ,that one can learn

ac twal. conditions i n any given area,

The r e su l t s of surveys i n the Eastern ~ e d i t e r r a n e a n Region so f a r show

t h a t there a re no s igni f icant overall differences i n prebalence between' the

Qrban and ru ra l areas. In fac t , pockets of greater prevalence~wqke,,found i n

cer ta in r u r a l (or peri-urban) d i s t r i c t s . For example, one ur l lage i n Arntnan

Dis t r i c t gave the only sputum positive findings (by d i r ec t microscopy), where

there were none i n the sample groups of &man tm. In Tunisia, within the

same governorate, the percentage of s ignif icant X-ray shadows found i n a . .. "

scat tered semi-nomadic community was about three times pore than i n an urban

I n India, t he sampling survey done i n 1955-1958 by the Indian Council of

Medical Research gave s imilar conclusions, namely, t ha t prevalence r a t e s in

c i t i e s , towns and vi l lages were generally of the same order *. Emever, exami-

nation of population cross-sections were much more revealing. I n Cdcut ta .

ci ty , f o r example, there were blocks with a prevalence of 50 per,1,000 and

others with only 3 per 1,000, with a t o t a l morbidity index of 16.3 per 1,000.

Further evidence comes f r m the surveys i n Kenya. The peri..urban area

of I(ambu outside Nairobi c i t y showed s igni f icant ly higher prevalence than

Nairobi, Signif icarit differences were a18 o observed bebeen t r i b e s l i v ing

within the ci ty .

It would seem f a i r l y safe t o s t a t e t h a t i n concentrated groups of popula-

t i on with bad soc io~econmic conditions, such as slum areas of large c i t i e s ,

there is no doubt t h a t a very high prevalence of tuberculosis w i l l be found.

An example of t h i s is 'the D jebel Lahmar area of Tunis, which had a prevalence

of 25% (act ive and inactive tuberculosis) and 13% (act ive tuberculosis) against

12 .b% and 5.7% correspondingly fo r three other governorates of Tunisia.

The Regional Tuberculosis adviser i s of the opinion t h a t comparisons of

survey figures between d i f fe rent countries might be misleading ~ m l e s s the s&e

c r i t e r ion fo r reading tuberculous or s ignif icant shadows is used. This i s

where WHO has an invaluable contribution i n i ts attempt t o introduce

sohe' uniform c r i t e r ion t o k k e data comparhble between d i f fe rent countries

and regions,

RADIOGRAPHIC AND TUBERCULIN TEST FINDINGS

(In $ of examined)

from selected surveys made by WHO i n the Eastern Mediterranean Region and Africa

Jordan Tunisia Libya Sudan Nairobi

a) Infected population (Tuberculin t e s t with Mx 1 TU)

a l l ages

10-14 years

b) Cases with X-ray shaduws indicative of Tuberculosis

Active and inactive

Active on ly