V Pan American Conference of National Directors of …hist.library.paho.org/English/PUB/PBOS222.pdf · El Salvador DR. ENRIQUE CLAVEAUX Uruguay DIRECTOR AUXILIAR ... Castillo Plaza,

V Pan American Conference ofNational Directors

of Health(Final Act)

Publication 222 July 1946

PAN AMERICAN SANITARY BUREAUWASHINGTON, D. C.

U.S.A.

FUNCIONARIOSDE LA

OFICINA SANITARIA PANAMERICANA(OFFICERS OF THE PAN AMERICAN SANITARY BUREAU)

DIRECTOR

DR. HUGH S. CUMMING

Surgeon General (Retired) U. S. Public Health Seroice

VICEDIRECTOR

DR. JORGE BEJARANO

Colombia

CONSEJEROS (COUNSELORS)DR. VÍCTOR ARNOLDO SUTTER

El Salvador

DR. ENRIQUE CLAVEAUX

Uruguay

DIRECTOR AUXILIAR (ASSISTANT DIRECTOR)DR. JOHN R. MURDOCK

Servicio de Sanidad Pública de los Estados Unidos

SECRETARIO (SECRETARY)DR. ARÍSTIDES A. MOLL

Director, Boletin de la Oficina Sanitaria Panamericana

VOCALES (MEMBERS)

Representantes designados por las siguientes Repúblicas:

PARAGUAY

HAITÍ BOLIVIAHONDURAS REPÚBLICA DOMINICANAGUATEMALA PANAMÁ

MIEMBROS DE HONOR (HONORARY MEMBERS)

DR. Jobo DE BARROS BARRETO, Presidente de HonorBrasil

DR. CARLOS ENRIQUE PAZ SOLDÁN

Perúl

DR. LUIS GAITÁN

Guatemala

DR. MANUEL MARTÍNEZ BÁEZ

Mézico

V PAN AMERICAN CONFERENCE OF NATIONAL DIRECTORSOF HEALTH

(Held in Washington, D. C., April 22-29, 1944)

FINAL ACT

The V Pan American Conference of National Directors of Healthopened in Washington, April 22, 1944, with a preliminary session inwhich Dr. Hugh S. Cumming, Director of the Pan American SanitaryBureau, and Dr. Arístides A. Moll, its Secretary, were elected by acclama-tion President and Secretary-General, respectively, of the Conference.The following Vice Presidents were also chosen: Dr. Manuel MartínezBáez, of Mexico; Dr. Eugenio Suárez, of Chile; Dr. César GordilloZuleta, of Peru, and Dr. Leopoldo Izquieta Pérez, of Ecuador.

The opening session was held April 24, 1944, at 11:15 in the morning,and was presided over by Dr. Hugh S. Cumming, Director of the PanAmerican Sanitary Bureau. It was attended by the majority of theDiplomatic Representatives of the American Republics, the high officialsof the Pan American Union, and a large medical and lay audience.Addresses of welcome were given by the Hon. A. A. Berle, Jr., AssistantSecretary of State of the United States, Dr. Leo S. Rowe, Director Gen-eral of the Pan American Union, Dr. Thomas Parran, Surgeon Generalof the U. S. Public Health Service, and Dr. Hugh S. Cumming as Directorof the Pan American Sanitary Bureau; and responses in the name of theDelegates of the Republics represented were made by Dr. Joao de BarrosBarreto of Brazil and Dr. Félix Hurtado of Cuba. All the addressesappear in the Proceedings.

The first plenary session of the Conference was held in the afternoon ofApril 24, 1944, under the Presidency of Dr. Hugh S. Cumming, Directorof the Pan American Sanitary Bureau, after which the Vice Presidentsassumed the chair in rotation.

COMMITTEES

The Conference appointed the following Committees:

Credentials: Dr. Jules Thébaud, Haiti; Dr. Alfonso Orozco, Colombia; Dr.Roberto Quesada, Costa Rica; and Dr. Guillermo Garcíia de Paredes, Panama.

Quarantine: Dr. G. L. Dunnahoo, United States; Dr. C. A. Alvarado, Argen-tina; Dr. Gonzalo Corbalán, Chile; Dr. Andrés Avello, Cuba; Dr. L. F. Thomen,Dominican Republic; Dr. C. Estévez, Guatemala; Dr. Plésance Télémaque, Haiti;Dr. Gustavo Viniegra, Mexico; Dr. Miguel Olivei y Silva, Paraguay; Dr. CésarGordillo Zuleta, Peru; Dr. C. P. Brown, Canada; Sir Rupert Briercliffe, BritishWest Indies; Dr. A. E. Wolff, Dutch Guiana; Dr. J. R. Arends, Curacáo; Dr. T. J.Hallinan, Jamaica, and Dr. J. D. Long, Senior Traveling Representative, PanAmerican Sanitary Bureau. It was agreed that any Chief of Delegation wishingto take part in its discussions would also be a member.

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PAN AMERICAN SANITARY BUREAU

Program for the XII Pan American Sanitary Conference: Dr. A. Castillo Plaza,Venezuela; Dr. G. L. Dunnahoo, United States; Dr. Manuel Martínez Báez,Mexico; Dr. Víctor Arnoldo Sutter, El Salvador; Dr. Alfonso Orozco, Colombia;Dr. Joao de Barros Barreto, Brazil; Dr. Eugenio Suárez, Chile, and Dr. AristidesA. Moll, Pan American Sanitary Bureau.

Resolutions: All the Chiefs of Delegation, namely, Dr. C. A. Alvarado, Argen-tina; Dr. Joao de Barros Barreto, Brazil; Dr. Eugenio Suárez, Chile; Dr. AlfonsoOrozco, Colombia; Dr. Roberto Quesada, Costa Rica; Dr. Félix Hurtado, Cuba;Dr. L. F. Thomen, Dominican Republic; Dr. Leopoldo Izquieta Pérez, Ecuador;Dr. Víctor Arnoldo Sutter, El Salvador; Dr. C. Estévez, Guatemala; Dr. JulesThébaud, Haiti; Dr. Romualdo Zepeda, Honduras; Dr. Manuel Martínez Báez,Mexico; Dr. Luis M. Debayle, Nicaragua; Dr. Guillermo García de Paredes,Panama; Dr. Ramón Prieto, Paraguay; Dr. César Gordillo Zuleta, Peru; Dr.Thomas Parran, represented by Dr. G. L. Dunnahoo, United States; Dr. RafaelSchiaffino, Uruguay; Dr. A. Castillo Plaza, Venezuela; and also Dr. C. E. PazSoldán of Peru and Dr. Arístides A. Moll, Pan American Sanitary Bureau.

Upon presentation of the report of the Chairman of the Committee onCredentials, the powers of the following Delegates were approved:

Argentina: Dr. C. A. Alvarado, Director, National Malaria Division. Brazil:Dr. Joáo de Barros Barreto, National Director of Health. Chile: Dr. EugenioSuárez*, National Director of Health; Dr. Gonzalo Corbalán, Chief, Division ofQuarantine, National Ministry of Health, and Dr. Benjamín Viel, Chief, Divisionof Epidemiology, National Ministry of Health. Colombia: Dr. Alfonso Orozco,Secretary General, National Ministry of Health. Costa Rica: Dr. Roberto Que-sada, Consul of Costa Rica in San Francisco. Cuba: Dr. Félix Hurtado, NationalUnder-Secretary of Health; Dr. Domingo F. Ramos, Director, Finlay Institute;Dr. Moisés Chediak, Director, National Health Laboratory; Dr. Andrés Avello,Assistant Chief of Quarantine; and Dr. Mario Le-Roy, Secretary, Finlay Institute.Dominican Republic: Dr. L. F. Thomen, National Under-Secretary of Health;Sr. Virgilio Pérez Bernal, Sanitary Engineer, National Department of Health; andSr. Salvador Sanlley y Gómez, Sanitary Engineer, National Department of Health.Ecuador: Dr. Leopoldo Izquieta Pérez*, National Director of Health, and Dr.Atilio Macchiavello, Director, National Institute of Health. El Salvador: Dr.Víctor Arnoldo Sutter, National Director of Health. Guatemala: Dr. C. Estévez,National Director of Health. Haiti: Dr. Jules Thébaud, National Director ofHealth, and Dr. Plésance Télémaque, Chief, Division of Quarantine. Honduras:Dr. Romualdo Zepeda, Secretary, National Department of Health; Mexico: Dr.Manuel Martínez Báez, Under-Secretary of Health and Public Welfare; Dr.Gustavo Viniegra, Chief, Division of Quarantine, National Department of Health;Dr. Guillermo Román y Carrillo, Chief, Division of Vital Statistics, NationalDepartment of Health; and Dr. Javier Baz Manero, Secretary of Delegation.Nicaragua: Dr. Luis M. Debayle, National Director of Health. Panama: Dr.Guillermo García de Paredes, National Director of Health. Paraguay: Dr.Ramón Prieto, National Director of Health, and Dr. Miguel Oliveira y Silva,Technical Adviser, National Ministry of Health. Peru: Dr. César GordilloZuleta*, National Director of Health, and Dr. C. E. Paz Soldán, Professor ofHygiene. United States: Dr. Thomas Parran, Surgeon General, U. S. PublicHealth Service; Brig. Gen. J. S. Simmons, M.C., U. S. Army; Dr. R. C. Williams,Assistant Surgeon General, U. S. Public Health Service; Capt. T. J. Carter, M.C.,

* Also present as a member of the Directing Council of the Pan American Sanitary Bureanu.

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U. S. Navy; Medical Director G. L. Dunnahoo, Chief, Division of Quarantine,U. S. Public Health Service; and Dr. R. E. Bodet, Assistant Chief, Division ofQuarantine, U. S. Public Health Service. Uruguay: Dr. Rafael Schiaffino,National Director of Health, and Dr. Enrique Claveaux, Director, NationalInstitute Infectious Diseases. Venezuela: Dr. A. Castillo Plaza, NationalDirector of Health, and Dr. José Ignacio Baldó, Chief, Division of Tuberculosis,National Ministry of Health.

In accordance with regulations, the following were present at theConference as ex offlio members: Dr. Hugh S. Cumming, Director of thePan American Sanitary Bureau; Dr. Arístides A. Moll, Secretary of thePan American Sanitary Bureau; Dr. John D. Long, Chief TravelingRepresentative of the Bureau; and Dr. A. González-Revilla, Attachéof the Embassy of Panama in Washington and Member of the DirectingCouncil of the Bureau.

Also attending the meetings as representatives of the Pan American SanitaryBureau were: Drs. Arnoldo Gabaldon, Venezuela, Henry Hanson, UnitedStates, A. S. Ayroza-Galvao, Brazil, and Luis Vargas, Mexico, members ofthe Pan American Committee on Malaria; Dr. R. E. Dyer, United States, of thePan American Committee on Typhus; Drs. E. V. McCollum, R. A. Harris, andW. H. Sebrell, United States, of the Pan American Committee on Nutrition, andDr. Abel Wolman, United States, of the Committee on Sanitary Engineering; andDrs. Edward C. Ernst, Assistant Director, J. R. Murdock, A. Donovan, and J. S.Spoto, Traveling Representatives; and Mr. Rafael Martinez, Dr. O. Vargas, andMr. Donald L. Snow. As guests of honor there were present, from Canada, Dr.G. D. W. Cameron, Chief, Laboratory of Hygiene, and Dr. C. P. Brown, Chief,Division of Quarantine, Immigration Medical and Sick Mariners' Services; BritishWest Indies, Sir Rupert Briercliffe, Medical Adviser to the Comptroller ofDevelopment and Welfare; Dutch Guiana (Surinam) Dr. A. E. Wolff, Director,Hospital Service, Department of Health; Curaçáo, Dr. J. R.. Arends, Office ofPublic Health; Jamaica, Dr. T. J. Hallinan, Chief Medical Officer; Office of theCoordinator of Inter-American Affairs, Brig. Gen. Geo. C. Dunham, Col. AlbertR. Dreisbach, and Lt. Col. H. Gotaas; Pan American Airways, Drs. F. H. Shillitoand L. T. Coggeshall; Taca Airways, Inc., Col. J. B. Pate; Transcontinental andWestern Airlines, Dr. Emerson Day; Rockefeller Foundation, Drs. H. H. Muenchand W. A. Sawyer; and the Commonwealth Fund, Mr. E. K. Wickman. Therewere also present, as observers, several distinguished physicians and scientistsfrom various Republics, including Dr. Carlos D. Céspedes of Costa Rica, Dr. M.Lares Gabaldón, Dr. Gustavo Stolk Mendoza, and Sr. Abel Mantilla, of Venezuela;and officers of the Food and Drug Administration and Bureau of Animal Industryof the United States, and of the Office of the Coordinator of Inter-AmericanAffairs, the U. S. Public Health Service, and the Army and Navy Medical Corps.

As may be seen in the Proceedings, the sessions offered many excellentoccasions for the interchange of ideas and experience regarding thenumerous and important problems confronting the various AmericanRepublics, many of them problems accentuated by the war. Thenumber in attendance was larger than at any previous Conference, andall the sessions were characterized by the high quality of the reports andpapers presented and by the constant spirit of cooperation and fraternity

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which reigned over the deliberations. An innovation which met withmuch approval was the holding, simultaneously with the general sessions,of meetings of some of the Committees of the Bureau and of the Con-ference, such as those on Malaria and Quarantine.

RESOLUTIONS AND RECOMMENDATIONS

After thorough discussion, the motions, resolutions, and votes whichappear below were approved unanimously:

COMMITTEES

The Fifth Pan American Conference of National Directors of Health, recogniz-ing the importance of the reports presented to it by the Permanent Committeesof the Pan American Sanitary Bureau, agrees to incorporate these reports in itsFinal Act as an expression of its appreciation and also as a demonstration of theconcrete progress in continental public health cooperation to which they bearwitness.'

The V Pan American Conference of National Directors of Health, consideringthe desire expressed by the Delegations of several countries to see new Pan Ameri-can Committees created on various subjects, such as leprosy, rural hygiene, socialsecurity, and sera and vaccines, approves this idea in principle, but recommends:(1) that until the funds of the Pan American Sanitary Bureau permit of otheraction, these new Committees be considered or designated "Special" Committees,their work to be financed by subsidies offered by the Governments of the countrieswhose representatives make up their membership.

PAN AMERICAN SANITARY CODE

The V Pan American Conference of National Directors of Health, recognizingthe necessity of revising in the light of the latest scientific knowledge a treaty suchas the Pan American Sanitary Code, which has been so extremely useful since itspromulgation and which should be maintained at its present high place in Ameri-can public health, recommends: that the Pan American Sanitary Bureau appointa Committee of three to five members to collect the necessary data and prepare atext for a new Pan American Sanitary Code to be presented to the various nationaldepartments of health at least six months before the XII Pan American SanitaryConference, so that they may express their opinions upon it, and that the Com-mittee then prepare, taking into account the changes suggested, a revised text tobe considered by the Conference.

It also recommends that this Committee take charge of the drafting of a Modelor Standard Public Health Code, in accordance with the suggestion of the IVConference of Directors.

QUARANTINE

The V Pan American Conference of National Directors of Health recommendsthat a special Sub-committee be appointed which shall be given the opportunitYto study and analyze the preliminary report presented during this Conference bythe Chairman of the Committee on Quarantine. It shall then present to theCommittee on Pan American Sanitary Code before the end of June, 1945, a com-plete and definite report which the latter, after the necessary consultations, shall

1 See Appendix, p. 11.

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SANITARY CONFERENCE

submit to the XII Pan American Sanitary Conference, to be held in Caracasin 1946.

SOCIAL SECURITY

The V Pan American Conference of National Directors of Health recommendsthat a Committee be created to study the relations between Social Security andPublic Health, and that the Pan American Sanitary Bireau arrange for a directinterchange of views between this Committee and the International Labor Office,and that said Committee be authorized to prepare a complete report on thissubject for the XII Pan American Sanitary Conference, to be held in Caracas in1946. During the preparation of its report, the Committee should obtain completeinformation on the role played by National Public Health Services within theSocial Security organization, and the control which they actually exert over themedical activities of that body.

EXCHANGE OF EXPERTS

The V Pan American Conference of National Directors of Health recommendsthat through the intermediation of the Pan American Sanitary Bureau there bechosen health officers or other health experts from different countries to rendertemporary service in other Republics as special advisors; and that in such casesthe country or institution requesting the services of these experts pay their traveland maintenance expenses, while their salaries continue to be paid by their owncountry.

FELLOWSHIPS

The V Pan American Conference of National Directors of Health recommendsthat the American countries which have centers for research and for education inPublic Health and Welfare endeavor to create the greatest possible number ofscholarships or travel fellowships for the training or exchange of technicians,from the official institutions of the rest of the American countries; that they offersuch fellowships to the Governments of sister countries; that there be establisheda minimum standard of requirements for securing such fellowships; that the chan-nel of requesting, transmitting, and obtaining such fellowships be made uniform,and that it be placed in the Pan American Sanitary Bureau; that the Pan AmericanSanitary Bureau accept this responsibility and make preparations to carry it out;and that the institutions which so generously contribute to the training of expertsin public health and welfare make a financial contribution to assist the Pan Ameri-can Sanitary Bureau in carrying out this task.

PINTO OR CARATE

The V Pan American Conference of National Directors of Health recommendsto the governments of the Americas: (a) that they consider among their healthproblems that brought about by the presence of pinto; (b) that they encouragescientific research upon it, especially on its transmission, with a view to its possiblecontrol; (c) that they stimulate its control through all possible means, especiallyby the establishment of free treatment centers in the most severely infectedlocalities; (d) that they establish a systematic and regular exchange of informa-tion regarding the work accomplished; and (e) that they endeavor to adapt theirresearch and control activities in regard to pinto to a uniform program so that theresults obtained may be used for comparison purposes.

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TEACHING OF FIRST AID

The V Pan American Conference of National Directors of Health, consideringthe fact that traffic accidents are daily increasing as a result of motorized trans-portation, and that the members of the police force are frequently the individualswho make first contact with the victims of such accidents, recommends to therespective governments that they organize the teaching of First Aid to the person-nel of such forces, such as the instruction given in the courses carried out by,among other organizations, the National Red Cross Societies, which use themethods and measures employed by the American Red Cross.

PUBLIC HEALTH CAREER SERVICE

The V Pan American Conference of National Directors of Health recommendsthat careful attention be given to the possibility of creating a public healthcareer service within the political traditions of each country, giving to it a properdignity, with liberty in scientific matters and a due amount of social coordination,as an essential and complementary measure to the creation of Ministries andSecretariats of Health, and as a guaranty both of the perfecting of already estab-lished inter-American health relations and of the successful confronting of thegrave medico-social problems which have been brought about by the war and ofthose which will arise in the post-war period and under the future worldorganization.

CREATION OF PUBLIC HEALTH ATTACHBÉS

The V Pan American Conference of National Directors of Health, consideringthe necessity of coordination of public health action, of a better knowledge of thepublic health organization and problems of the countries of the continent, and ofbetter and greater ties between health authorities, resolves to recommend to thesignatory governments the creation of the diplomatic post of Public HealthAttaché, in the same form and with the same prerogatives as the other posts ofattaché, and that in the meantime the signatory governments, in accordance withthe authorization given in Article XIX of the Pan American Sanitary Code,designate a health officer attached to the Embassies or Legations, at least in theheadquarters of the Pan American Sanitary Bureau and in their neighbor coun-tries; and recommends to the governments of the countries which do not alreadyhave it the creation of a special division for the handling of international publichealth relations.

HEALTH CERTIFICATES

The V Pan American Conference of National Directors of Health recommendsthe suppression of the so-called health certificate for passengers who are notimmigrants or who are transients, and with respect to the countries in which thecertificate is required by law, that until such time as the legislation is modified,only certificates issued by health authorities, and gratuitously, be accepted.

COMMEMORATIVE STAMPS

The V Pan American Conference of National Directors of Health recommendsthat in honor of Pan American Health Day the various Republics issue commemo-rative postage stamps to circulate in the month of December, which will be usedto emphasize the benefits of health and to honor scientists who have contributedto the improvement and maintenance of health throughout the ages and especiallYin the Americas.

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SANITARY CONFERENCE

VITAL STATISTICS

The V Pan American Conference of National Directors of Health, to promotethe better knowledge of the incidence of and mortality from communicable dis-eases and of the vital statistics data of most public health importance, insiststhat attempts should be made to intensify not only the reporting by physiciansof even suspicious cases of communicable disease, but also the public healthadmínistrative measures necessary for the better knowledge of such cases anddeaths. It further recommends to the governments that they endeavor to bringabout, in the manner most adequate to local conditions, a better distribution ofphysicians, in order to make possible the better collection of statistical data,improved control of communicable disease, and better medical care in all regionsof the country, and it also accords a vote of support to the activities of the PanAmerican Committee on Epidemiological and Vital Statistics and urges theRepublics which have not yet appointed representatives to it that they do so inthe shortest possible time.

REGISTRATION AND CONTROL OF FOODS AND DRUGS

The V Pan American Conference of National Directors of Health recommendsthe appointment of a special Committee to study the unification of standards forthe public health registration of drugs and medicines and of control measures forfoods and drugs.

ZOONOSES

The V Pan American Conference of National Directors of Health, recognizingthe epidemiological importance of the animal diseases transmissible to man,recommends that the studies of their incidence and of the preventive measuressuggested by experience for their control, be intensified.

DRUG QUOTAS

The V Pan American Conference of National Directors of Health proposes thatthe Pan American Sanitary Bureau make the necessary representations so that theexport quotas of specific drugs and medicines be revised, and be allotted in propor-tion to the needs of the importing country rather than in relation to consumptionin previous years, bringing them as closely as possible to the quotas prevailing inthe country of production or manufacture, in accordance with the resolution of theXI Pan American Sanitary Conference regarding equal sacrifices among all theAmerican Republics.

PROGRAM OF THE XII PAN AMERICAN SANITARY CONFERENCE

The V Pan American Conference of National Directors of Health recommendsThe Pan American Sanitary Code as the main subject of the XII Pan AmericanConference, together with the following agenda:

Uniform regulation of food and drugs.Organization and activities of Health Centers and Units.Epidemiology of Malaria.Epidemiology of Tuberculosis.Zoonoses in general.Health Education.Control of Venereal Diseases.Health Problems Arising from the Post-War Period.It also recommends that six months before the Conference, the Pan American

Sanitary Bureau, in agreement with the National Directors of Health, suggest

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any modifications of this program which it considers necessary or opportune;that in the presentation of the subjects there be followed the system of rappor-teurs prescribed by the X Pan American Sanitary Conference; and that in additionto the formal program there be presented by each Delegation reports on themanner in which the recommendations of previous Conferences and of the Com-mittees have been carried out, and on the health progress achieved in therespective country during the period preceding the Conference.

PAN AMERICAN UNION

The V Pan American Conference of National Directors of Health, being in-formed of the resolution of the Governing Board of the Pan American Union,lon the motion of the Ambassador of Uruguay, the Hon. Carlos Blanco, secondedby the Hon. Cordell Hull, and the other members of the Board, to the effect thatthe Conference be felicitated for the work it is accomplishing, hereby expressesin its Final Act the appreciation of the members of the V Conference for thismessage of support, which is a demonstration of the spirit of ContinentalSolidarity as embodied in the Pan American Union, and a proof of the growingprogress of fraternal cooperation among the peoples of America.

OFFICE OF THE COORDINATOR OF INTER-AMERICAN AFFAIRS

The V Pan American Conference of National Directors of Health, recognizingthe beneficial and praiseworthy nature of the public health cooperation extendedto the majority of the countries of the continent by the Office of the Coordinatorof Inter-American Affairs, hereby officially expresses its gratitude for suchcooperation.

CANADA AND TuE WEST INDIES

The V Pan American Conference of National Directors of Health expresses itspleasure at seeing represented in the Conference the sister country of Canada andthe British and Dutch Colonies in America, and hopes that the participation ofthese countries will be continued and extended in the future, and avails itself ofthis opportunity to extend its greetings to Dr. G. D. W. Cameron, Chief of theHygiene Laboratory, and Dr. C. P. Brown, Chief of the Division of Quarantineand Immigration, of Canada; Sir Rupert Briereliffe, Medical Counselor of theChancellor of Promotion and Welfare of the British West Indies; Dr. A. E. Wolff,Director of the Hospital Service of the Department of Health, of Dutch Guiana(Surinam); Dr. J. R. Arends of the Department of Health of Curacáo; and Dr.T. J. Hallinan, Director of Medical Services of Jamaica.

PAN AMERICAN HEALTE DAY CONTEST

The V Pan American Conference of National Directors of Health expresses itsappreciation to the Lily Tulip Cup Corporation for its generous initiative inproviding funds for an essay contest among students of the Americas which willbe a means of spreading health knowledge and of rendering tribute to those whoparticipated in its acquisition.


The V Pan American Conference of National Directors of Health expresses avote of applause to the Directing Council of the Conference, and especially to itsvenerable President, Dr. Hugh S. Cumming, and its active and cordial Secretary,Dr. Aristides A. Moll.

The V Pan American Conference of National Directors of Health, in approvingthe report submitted to its consideration by the Director of the Pan American

'See Appendix, p. 10.

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SANITARY CONFERENCE

Sanitary Bureau, hereby records its praise of it, and reiterates its confidence inDr. Hugh S. Cumming because of his consecration to the work of the Bureau.

DAUGETERS OF THE AMERICAN REVOLUTION

The V Pan American Conference of National Directors of Health hereby ex-presses its appreciation to the patriotic society, Daughters of the AmericanRevolution, for its courtesy in providing space in its beautiful building for mem-bers of the staff of the Pan American Sanitary Bureau.

VOTES OF APPLAUSE

The V Pan American Conference of National Directors of Health expresses itsappreciation to all the persons and institutions which have extended it such ahospitable and friendly welcome, including His Excellency, the Secretary of Stateof the United States, the Hon. Cordell Hull; the Hon. Adolf A. Berle, Jr. and MrsBerle; Mr. Nelson Rockefeller, Coordinator of Inter-American Affairs; theNational Institute of Health; the Naval Hospital; the Pan American MedicalAssociation; the International Medical Club; aad especially to the Departmentof State of the United States, which did so much to facilitate the travel of theDelegates; and to the personnel of the Secretariat, which was so zealous in attend-ing constantly and amiably to the wishes of the members.

The closing session was held Saturday, April 29, 1944, at 5:00 p.m.,under the presidency of Dr. Hugh S. Cumming. The remarks made atthis meeting appear in the Proceedings of the Conference.

Signed in the City of Washington on April 29, 1944, a copy to be sent to each oneof the Delegations and also through diplomatic channels to the Governments ofeach of the American Republics; the original to be kept in the archives of the PanAmerican Sanitary Bureau.

Signed:

MANUEL MARTfNEz-BÁEZVice President

(Mexico)CÉSAR GORDILLO-ZULETA

Vice President(Peru)

ARfSTIDEs A. MOLL

Secretary-General

C. A. ALVARDO(Argentina)

JoAo DE BARROS BARRETO

(Brazil)GONZALO CORBALÁN

(Chile)BENJAMfN VIEL

(Chile)ALFONSO OROZCO

(Colombia)

HUGH S. CUMMINGPresident

ROBERTO QUESADA

(Costa Rica)FÉLIX HURTADO

(Cuba)DoMINGo F. RAMOS

(Cuba)MoISÉs CHEDIAK

(Cuba)ANDRÉS AVELLO

(Cuba)MARIO LE-RoY

(Cuba)L. F. TROMEN

(Dominican Republic)VIRGILIO PÉREZ-BERNAL

(Dominican Republic)SALVADOR SANLLEY Y G6MEZ

(Dominican Republic)ATILIO MACCHIAVELLO

(Ecuador)

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VfCTOR ARNOLDO SUTTER

(El Salvador)EUGENIO SUÁREZ,

Vice President(Chile)

LEOPOLDO IZQUIETA-PÉREZ

Vice President(Ecuador)

C. ESTÉVEZ(Guatemala)

JULES TEÉBAUD

(Haiti)PLÉSANCE TÉLEMAQUE

(Haiti)ROMUALDO ZEPEDA

(Honduras)GUSTAVO VINIEGRA

(Mexico)GUILLERMO ROM-N Y CARILLO

(Mexico)JAVIER BAZ-MANERO

(Mexico)LuIs M. DEBAYLE

(Nicaragua)GUILLERMO GARCfA DE PAREDES

(Panama)

RAMÓN PRIETO

(Paraguay)MIGUEL.OLIVEIRA Y SILVA

(PARAGUAY)

C. E. PAZ SOLDÁN(Peru)

THOMAS PARRAN

(United States)J. S. SIMMONS

(United States)R. C. WILLIAMS

(United States)T. J. CARTER

(United States)G. L. DUNNAHOO

(United States)R. E. BODET

(United States)RAFAEL SCHIAFFINO

(Uruguay)ENRIQUE CLAVEAUX

(Uruguay)A. CASTILLO PLAZA

(Venezuela)JosÉ IGNACIO BALD6

(Venezuela)

APPENDIX

To the Hon. Dr. Hugh S. Cumming,President of the Fifth Pan American Conference of National

Directors of Health

We are honored to inform you that at the meeting of the Governing Board ofthe Pan American Union which took place Wednesday, April 26, Dr. Carlos Blanco,Ambassador of the Republic of Uruguay, moved that cordial congratulations beconveyed to you as President of the Fifth Pan American Conference and to allthe distinguished members in attendance.

Dr. Blanco paid tribute to the meritorious work being carried out by the PanAmerican Sanitary Bureau, to the fruitful labors of the Directors of Health andof the Counselors and Technicians in all of the countries of America, and to theimportant program of the Fifth Pan American Conference of Directors of Health,which all those in attendance will strive to carry out.

The President of the Governing Board, the Hon. Cordell Hull enthusiasticallyseconded the motion made by the Ambassador of Uruguay, which was unanimouslyapproved by all the members of the Board.

In transmitting to you this resolution, we join in its sentiments, and we present

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to you and to the Conference of Directors, congratulations from the officials andthe staff of the Pan American Union.April 27, 1944(Signed) L. S. ROWE (Signed) PEDRO DE ALBA

Director General of the Assistant Director of thePan American Union Pan American Union and

Secretary of the GoverningBoard.

RECOMMENDATIONS OF THE PAN AMERICAN COMMITTEEON MALARIA

The Malaria Committee of the Pan American Sanitary Bureau con-tinues in the conviction that malaria is one of the most important, if notthe major, of the health problems of America, and presents in its secondannual report the following recommendations and conclusions, which arecomplementary to its 24 preceding ones:*

(1) That the personnel utilized by antimalaria services be full-time,and that before additional part-time personnel are employed thosealready employed should be raised to full-time.

(2) That countries situated in the tropical and subtropical regions usefor the preliminary training of their technical personnel the coursesoffered by the National Malaria Service of Brazil and the Division ofMalariology of Venezuela.

(3) The Committee reports that in addition to the anopheles identi-fication service, its associated laboratories are prepared to assist in theclassification of malaria parasites.

(4) That the various countries increase the work of epidemiologicalsurveys of malaria in order to outline accurately the regions affected bythe disease.

(5) That the Committee on Epidemiological and Vital Statistics ofthe Pan American Sanitary Bureau take steps to secure the adoption bythe various countries of the classification for deaths without medicalattention which was proposed in the 20th recommendation of theprevious report of the Malaria Committee.

(6) That the aforesaid Statistical Committee take steps to secure themodification by the International Commission on Nomenclature ofCauses of Death of the malaria nomenclature, so that it will read asfollows:

28. Paludism and Malaria, (a) clinical diagnosis only, (b) infectionwith Plasmodium vivax, (c) infection with P. falciparum, (d) infectionwith P. malariae, (e) combined infections, and (f) hemoglobinuric(blackwater) fever.

*See Publication 202

11

NUTRITION AND HUMAN WELFARE

REPORT OF THE PAN AMERICAN COMMITTEE ONNUTRITION*

Our knowledge of the number and chemical nature of the nutrients forthe maintenance of a high standard of health, their distribution in naturalfoods and the symptoms caused by deficiency or lack of one or more ofthem, is the result in great measure of experiments on animals. So alsohas the spectacular contrasts between the effects of good and poor dietsin animals led to interest in the application of the new knowledge toimprovement of human health through improvement in the nutritionalstatus of people wherever malnutrition is found. In the earlier years ofthe study of human nutrition problems the primary interest was infinding out the nature and extent of inadequacy of dietaries in variousregions where health impairment was known or was suspected to existbecause.of inadequacy of the food supply. In fact this is still true, as ismade clear by an examination of the kinds of nutrition studies which arebeing published in several countries. Further nutritional surveys, anddemonstrations of the benefits which may be achieved through dietaryimprovement are of high value in that they serve to arouse interest indoing something about the problems relating to food and health.

As nutrition problems in various geographic areas have been studied it has be-come evident that knowing what the trouble is, and what should be done to remedysituations which exist, serve only to confront us with economic, agricultural andadministrative problems, for which, in many instances no easy solution presentsitself. It is my purpose on this occasion to mention some of the topics whichshould be given consideration in this conference in order that we may progress asrapidly as possible in formulating comprehensive programs for achieving our ob-jectives in nutrition improvement in different parts of the Americas and their ad-jacent islands.

A common cause of dietary inadequacy in man is the devotion of the agricul-tural resources of an area too largely to the growing of a cash crop such as tobaccoor sugar, and too little attention to the growing of food plants for local consump-tion. In the past the temptation to grow cash crops and to neglect food produc-tion has been so great that change has been difficult to bring about. However,the facts which can and are now being used to demonstrate health significance ofan improved food supply should make it easier to change agricultural practices inthe desired direction. When people realize that their health standards can beraised by dietary improvement, change of attitude toward the uses of the landare certain to be more easily brought about than was possible when such knowledgewas not available. It is not clear how the diversion of much land to food produc-tion in areas where the economy has long been based upon an export trade in a cashcrop can be accomplished without lowering the income of the area owing to de-creased production of the cash crop which would follow decreased acreage devoted

* Submitted by Dr. E. V. MeCollum, Chairman of the Committee., to the Conference of National Di-rectors of Health in Washington, D. C., on April 22-29, 1944.

12

NUTRITION

to it. If the sales volume and monetary return from the accustomed cash crop arereduced the economy of the area attempting dietary reform may be disturbed bothas to crop sales and to imports. Such considerations must receive the attentionof economists and agricultural experts before large scale programs can be mappedout.

It is a matter of common knowledge that the Americas produce largesurpluses of foods for export to Europe when conditions are normal.But in both North and South America, Central America and variousislands near our continents portions of the population cannot meet theirfood needs. In general it is the temperate zones which are the areasof excess food production. Our Southern States, Central America, theCaribbean area and Tropical South America, have until now not gen-erally been self-sufficient in respect to food growing. In these areasit would seem that increased production of certain foods is likely to besound from every point of view. This can doubtless be accomplishedwithout in any degree disturbing the normal flow of wheat, flour, riceand other agricultural products from temperate toward the warmerareas. If increased transport of foods to Tropical areas is to be madepossible, there must be an increase in purchasing power of the inhabi-tants in order that they may buy them.

Wherever people do not have sufficient of the right kinds of foods in-creased local production may well be advised with the expectation thatthe increased food consumption resulting from gardening by the familywill not reduce their food purchases significantly because home produc-tion will generally not increase the supply to an extent greater than thedeficit in nutrients which brought the family to a state of inadeqatenutrition.

In areas where there is abundance of foods, the supply being fullyadequate after satisfying the export markets, there is frequently foundto be an element in the population which does not find the means tosecure its quota of foods for adequate nutrition. Again it is an eco-nomic problem. Prospects indicate that in the post-war period a greatereffort than has ever before been made will be put forth to develop co-operative relations between nations. The importance of the food prob-lem, which means agricultural problems distinctive and sometimesunique in several types of geographic environment, character of soils,transport facilities and the economic factors which enter into suchtransport, overshadows in importance other aspects of the health prob-lems associated with the food supply.

There are certain areas, of which Puerto Rico is an example, where the popula-tion density is so great that the food problem has become one of special gravity.There the economic problem is the primary one under conditions of unhamperedshipping, when much sugar and tobacco are exported and much food is imported.Such areas must be carefully studied to determine the wisest policy relative to the

13


production of non-food crops, or cash crops for export, and the utilization of theland for food growing for home consumption. Both economic and sociologicalpolicies are involved in the alleviation of the dietary situation.

The problems of food production, food transportation, and fair distribution toall population groups irrespective of their economic status, are mentioned andemphasized here before discussing the problems of education of the people in mat-ters relating to food values and the selection of foods so as to provide fully ade-quate diets, because one of our most fundamental problems is the conservation andutilization of the land to the best possible extent, one feature of which program isthe production of an adequate food supply. We have many examples in recentdecades of the introduction of greatly improved efficiency in certain types of agri-culture. We must have food production and the facilities for its distribution incommercial channels before we can attain success in other features of the broadnutrition program. This means that, since every important food plant is temper-mental as to soil type, temperature range, hours of sunshine, amount and distribu-tion of rainfall, each can be grown only under certain conditions. The distribu-tion of foods necessitates the maintenance of trade communications. Especiallyin the warmer areas of the world there must be importation of several kindsof food staples. In general such food exchanges are desirable or necessary in otherparts of the world, even where diversified agriculture flourishes.

The Application of the Science of Nutrition to Health Problems.-We now possess a most valuable body of knowledge concerning thenature and occurrence of the essential nutrients, the amino acids derivedfrom proteins, the mineral elements which participate in physiologicalprocesses, the vitamins, the essential fatty acids, the caloric needs ofpeople living under different conditions. We have much information ofpractical value as to the stability of certain vitamins as affected by light,heat, exposure to oxygen, etc. But we still have much to learn aboutalmost every one of our more important foods. One highly importantfield of inquiry where there are serious differences of opinion among themost distinguished authorities, is the minimum allowances of variousnutrients for individuals of different ages, variously occupied in workat different degrees of energy expenditure, at different temperatures,and for different working periods, which are compatible with the main-tenance of high health standards. There are now available many care-fully collected data which show that the nutritive needs of pregnantwomen and of nursing mothers are not being provided in the case oflarge numbers of women.

Where people live under conditions of relative abundance and haveincomes sufficient to enable them to buy sufficient milk, meats, freshfruits and vegetables, as well as canned, cold-stored, or frozen foods,there is no difficulty in securing fully adequate diets. The necessityfor the inclusion of sufficient of the more important protective foods forthe purpose of supplementing cereal and other staple foods is now wellknown everywhere among informed people. But the diets of manymillions of peoples in various parts of the world are now, and for long

14

NUTRITION

must continue to be simple and monotonous, and of rather low palat-ability. It is the improvement of such dietaries to the maximum extentand in the most economical way that constitutes one of our pressingnutritional research problems.

As respects the correction of deficiencies such as iodine, iron, calcium, or othermineral element there is the possibility of direct addition of the substance to somestaple food such as a cereal flour or meal. We have vast vitamin resources in thepolishings of rice, in wheat germ, corn germ, brewer's yeast and other yeast andyeast concentrate, in immature leaves of several plants which might be driedand powdered and used as adjuvants to foods which are good sources of energyand protein but are deficient in vitamins. The cereal grains being eaten generallyin the form of their milled products stand in need of this type of supplementation.

As respects the protein moiety in the diets of simple and monotonous characterwhich are of the lowest cost type and sustain vast numbers of people in many areas,we are justified by recorded observations in making the generalization that it is ofrelatively low biological value. Cereal products and beans are often the mainsources of dietary proteins. We need further studies to discover, if possible, somesources of protein suitable for inclusion in the human diet, which has high supple-mental value for the proteins of white wheat flour, polished rice and corn. Atpresent the most effective source of such supplemental protein for wheat flour infoods of vegetable origin seems to be soy bean protein. It is also known thatyeast proteins improve the utilization of flour proteins, and that two per cent ofdried yeast serves this purpose well.

In this connection it should be mentioned that if it is economically practicableto include moderate amounts of meat, milk or egg in the human diet, this is theprocedure of choice for enhancing the biological value of the vegetable proteinswhich will in general form the principal source of protein. But there is everyprospect that for large elements in many populations it will not be economicallypracticable to supply these more expensive sources of proteins and other nutrientsin the near future. Hence the advisability of carrying on further researches todiscover the most effective supplemental protein sources in foods of vegetablenature.

Whereas in several countries in Europe and Asia it appears that the utilizationof land resources has already reached its maximum potentialities, it is clear that inneither of the Americas is this true except in certain islands. Indeed there are yetgreat opportunities for expansion of agriculture in certain areas and for the intro-duction of better farming methods, and also for systems which will make possiblethe production of two crops per year from the land. Our consciousness of thesignificance of making the right combinations of foods in order to secure diets ofgood to superior quality, will induce such planned land utilization by planning forthe production of crops which yield the most valuable food combinations.

In offering these suggestions for further researches on certain aspectsof our food problems, one is conscious that we are still inadequately in-formed concerning the needs of people in many areas. The first objec-tive, after recommending extension of specific researches of a funda-mental scientific nature, such as those dealing with various aspects ofeach of the essential nutrients, is inquiry into the nature and extentof dietary deficiencies wherever these occur. Such knowledge forms the

15


best foundation for future planning for improvement of human dietaries.Dietary surveys are at the present stage of our progress of considerablevalue since they delineate the nutrition problems of an area, and theyserve to stimulate interest in formulating a plan of action.

In looking forward to a long time program of educational work de-signed to improve dietaries great emphasis should be placed upon theeducation of as many as possible young women in nutrition and dietetics.The teaching of nutrition to all children of school ages is not only aneffective means of preparing the rising generation to appreciate the im-portance of right eating for safeguarding health, but also of directing theadult members of the family to the new knowledge and its significance.

Much progress has already been made in educating the employers oflabor to an understanding of the improvement in service which may beachieved through bettering the health of industrial workers. The extentto which fatigue may be reduced or alertness and aggressiveness increasedwill depend, of course, on the extent of malnutrition of the worker, butobservations on industrial groups seem to leave no doubt that there areconsiderable opportunities in this direction in certain population groups.We need much more inquiry in this field.

Obstetricians and pediatricians are becoming convinced that theyhave an important contribution to public health to make through theapplication in their medical practice of the newer knowledge of nutri-tion. It is clear that a great many infants might be born better endowedwith physical vigor than is now the case, and the literature of pediatricresearch clearly indicates that there is still a relatively large number ofinfants who are not fully protected against such easily preventable dis-orders as rickets and scurvy, although extraordinarily great progress insafeguarding infants and children against these defects due to malnu-trition has occurred in two decades.

There is much interest at present in the study of the symptoms and the chemicaland other tests by means of which the earliest signs of a score of specific types ofmalnutrition may be recognized. Such studies are primarily of interest to thephysicians and the biochemists. The researches bearing on this field of inquirycannot be praised too highly, for they are certain to have far reaching results.

One should not fail under present conditions to mention in this conference thespecial nutritional problems which have confronted nations because of war. Theconcern about the adequate feeding of military forces is greater than in any pre-vious war. The finding of ways and means for improving the health of workersin war industries has ocupied the attention of both military men and industrialexecutives. Both of these undertakings are of primary national concern.

The critical situations respecting food production and food allocationfor different population groups has necessitated food rationing. Limita-tions of supply of certain foods and their strategic importance have madenecessary price control. It is not possible for those participating in this

16

TYPHUS

conference to deal with all the aspects of the food problem. I have at-tempted to set before our conference the more obvious and importantobjectives toward which we must apply our efforts. A new departmentof knowledge, the knowledge of the role of diet in relation to health,has come to stand abreast of the hitherto recognized public health prob-lems such as the control of communicable diseases, improvements insanitation and the control of epidemics. Already, through the wide-spread prevention of rickets and scurvy in infants, children, and the armedforces, and the reduction to a considerable degree in the incidence of beri-beri and pellagra, outstanding achievements in the field of public healthhave been realized. There are still fields to conquer through the agencyof foods. We have come together today to report new researches and todiscuss several of the larger problems in nutrition in which we aremutually interested.

REPORT OF THE PAN AMERICAN COMMITTEE ONTYPHUS*

The Pan American Sanitary Bureau considering the public healthimportance of typhus and the other rickettsiases diseases in the Americasbecause of their extensive distribution (the presence of typhus has beenalready proven in fourteen countries and various foreign possessions inthe hemisphere) and its high incidence in certain regions; and in ac-cordance with the resolutions of the Pan American Sanitary Conferencein Rio, September 7-18, 1942, has organized the Pan American Com-mittee on Typhus for the study of this disease and the other Americanrickettsiases.

In Rio de Janeiro studies of the disease were suggested also alongthe following lines:

1. To determine the various rickettsial diseases existing in each country.2. To study the reservoirs and vectors of the rickettsias found in each country.3. To present the conclusions of their work at succeeding conferences.4. That the Health Authorities in the regions in which typhus is found and

where there are Indian populations attempt to secure the cooperation of these pop-ulations through the activity of nuclei selected among the Indians themselves asthe most direct and efficient means of lasting public health results.

The Pan American committee on Typhus plans to study:

The epidemiology of typhus and other rickettsiases found in the continent inorder to determine the series of factors which make their existence possible innature.

* Submitted by Dr. R. E. Dyer, Chairman of the Committee, to the Conference of National Directoraof Health in Washington, D. C., on April 22-29, 1944.

17


The standardization of methods of study so that the results obtained in thedifferent countries may be comparable with each other.

The search of more adequate methods of prevention and control of these 'dis-eases, including research into specific treatment and improvement of presenttherapy.

The development of this plan will comprise the study, as completelyand exactly as possible, of the geographic distribution and incidence ofrickettsiases in the hemisphere, of the characteristics and variationswhich they present in regard to season, climate, altitude, epoch, that isto say, in successive years, age, sex, race, occupation, place of residenceand all other epidemiological factors, such as the economic-social, of theaffected population.

To this end is recommended the improvement or intensification, inaccordance with the degree of development reached by typhus study ineach country, of the notification of cases occurring in their respectiveterritory, of the study of the characteristics of the affected regions, ofthe laboratory confirmation of clinical diagnosis, and of the type classi-fication of rickettsiae.

It would be advisable to select, in the countries where it is possible todo so, certain regions as experimental areas for the more detailed andcomplete investigation of the population factors related to these diseases.

The plan also includes the study of a sufficient number of strainsof rickettsiases from each country in order to learn their distribution ándpromote research on the biology and antigen composition of rickettsias.It includes the determination, classification and biological study of thevectors and of the manner in which they transmit the diseases. It in-cludes the determination, classification and biological study of thereservoirs of virus in nature and the study of parasitism or the relation-ship of the virus with the host.

The Committee considers it very advisable that each country under-take research to elucidate some of these points and that it establish orproceed to a continued and permanent study of rickettsiases in their re-spective territories.

The following steps have been taken towards the execution of this plan:Organization of the Pan-American Committee on Typhus with repre-

sentatives of the twenty-one republics of the Americas and Canada,'and sending to each of the governments of these countries the plan oforganization, a preliminary questionnaire and an invitation to appointa representative at the Committee. Some countries have consideredit unnecessary to be represented because rickettsiases are not an im-portant public health problem in their territory. Several countries have

l To date members have been appointed from the following countries: Argentina, Brazil, Bolivia,Colombia, Cuba, Costa Rica, Chile, Ecuador, Guatemala, Haiti, Mexico, Uruguay and Venezuela.

18

already filled in the questionnaire. The data furnished are being pub-lished in the Bulletin of the Pan American Sanitary Bureau.

During the meeting of the American Public Health Association inNew York in October 1943, an informal reunion of some members of thePan American Typhus Committee and the official delegations of certaincountries interested in the public health problem of this disease tookplace and certain suggestions were made at the time for the standardiza-tion of the study of typhus and other rickettsiases. These suggestionsand the epidemiologic table prepared by the Pan American SanitaryBureau for monthly reports on typhus and allied diseases were sent toall the members of the Committee so that they might comment on themand recommend the best methods for carrying them out. The Bureauis continuing the study of laboratory techniques which was also dis-cussed at the New York meetings.

The Pan American Sanitary Bureau has initiated a study of the Coxand R. Castafeda vaccines under natural conditions and the study of adelousing campaign in a civilian population using one of the new insecti-cides. The Bureau has also cooperated with the health authorities ofColombia, Guatemala and El Salvador in the preparation of programsfor the study and control of typhus in their territories and it has beenstudying the program of the Mexican Typhus Committee and exchang-ing ideas with its members. This program was discussed at the meetingin New York, and it was advised that the other countries should dosomething along similar lines.

In order to draw up complete programs on the points mentioned andto seek the most adequate procedures for carrying them out, the PanAmerican Sanitary Bureau plans to call together the members of thePan American Committee on Typhus at the earliest opportunity.

The Pan American Sanitary Bureau through the Committee offersall the technical cooperation at its command and places at the disposi-tion of the interested governments the consultative services of recog-nized authorities in this field when necessary, in connection with prob-lems referring to the study, control and treatment of these diseases.

19TYPHUS

REPORT OF THE PAN AMERICAN COMMITTEE ONSANITARY ENGINEERING*

The Sanitary Engineering Committee was created at the XI PanAmerican Sanitary Conference in Rio de Janeiro in 1942. It is com-posed of representatives of the departments of health and the departmentsof public works of Latin America, with representation from the sanitaryengineering profession in North America. Staff engineers of the PanAmerican Sanitary Bureau serve in its deliberations as ex-officiomembers.

In the intervening time since its creation, the Committee has set fortha series of future objectives, which have been published in the Bulletinof the Pan American Sanitary Bureau. The objectives were those whichappeared to be of most pressing wartime significance, and were notintended to cover then, nor do they now cover, the entire field of sani-tary engineering needs or prospective needs in the Latin American coun-tries. Later in this report more comprehensive objectives will be brieflyoutlined as guides for future sanitary engineering activity and as indica-tions to the health officers of the major problems which the Committeefeels will confront them in the course of the next five to ten years.

It has become obvious even within the short time of operation of the SanitaryEngineering Committee that a great deal of work lies ahead in this particular dis-cipline, which will require expanded professional forces, expanded budgetary al-lotments and increased numbers of sanitary works for the servicing of populationsdemanding and requiring such facilities.

While these objectives are still in the making, the Committee desires to pointout that sanitary engineering activities have moved rapidly forward in the coun-tries under consideration. A brief summary of these activities, with some refer-ence to their ultimate significance, is presented below.

Recent Sanitary Engineering Activities.-Requests for sanitary engi-neering services and advice from the Pan American Sanitary Bureauhave rocketed during the past biennium and the Bureau has had toaugment its engineering personnel considerably. From two sanitaryengineers, the number has already been increased to eight, with thefurther addition of an entomologist. Of these, six engineers and theentomologist are now operating from bases in Central America and twoengineers are stationed in Lima, Peru. In spite of this expansion, therange and extent of engineering facilities which can be made availableto the Pan American republics are still limited and activities have beenconcentrated mostly in the Central Caribbean area and the Pacific coastof South America.

One of the most recent and major undertakings of the engineeringstaff has been the extensive sanitary survey work performed in connec-

* Submitted by Dr. Abel Wolmnan of Johna Hopkins Universeity, Chairman of the Committee, to theConference of National Directors of Health in Washington, D. C., on April 22-29, 1944.

20

SANITARY ENGINEERING

tion with the Pan American highway project in Central America. Com-plete sanitary surveys have already been received from Sabinas Hidalgoin Mexico; Sola, Ayutla, Jutiapa, and Escuintla in Guatemala, andDavid and Santiago in Panama. The engineering part of these surveysembraces sanitary evaluations of the water supplies, means of sewagedisposal, milk supplies and milk handling methods, places handlingother food supplies such as abattoirs, public markets, ice cream plants,bakeries, bottling plants, and also eating and drinking establishments,malaria foci and methods for their control, disease-carrying mosquitoesand fly nuisances, and housing standards. These surveys have alreadyset a standard for similar projects along other sections of the Pan Ameri-can Highway.

Malaria control activities and accompanying entomological studies have pro-ceeded along a variety of fronts. Besides the malaria surveys made in the Repub-lics of Panama, Mexico, and Guatemala, extensive studies have been made in thelittoral areas surrounding Guayaquil, Ecuador, and also the Rimac, Chancay, andCafiete valleys of Peru. In the latter republic the Bureau has maintained parti-cularly close relations with the Anti-Malaria and Rural Sanitation Service. Atthe moment considerable assistance is being given in the organization and develop-ment of this malaria service. Through the services of the Bureau engineers, theinterchange of information between the various republics on malariacontrol methods, techniques, and allied subjects has been greatly fa-cilitated. In face of the existing scarcity of larvicides in Peru, the Bureauconducted a series of laboratory tests and field trials which resulted in the selec-tion of copper arsenite as a substitute for Paris green. It has played an integralpart in the design and construction of the copper arsenite factory for Peru whichis now in full production and is supplying all of the dust larvicide requirementsfor that country.

Other material shortages which vitally affect the public health havebeen alleviated to the extent of securing such items as liquid chlorine.On various occasions the cities of San Jose, Costa Rica, and Lima, Peru,have called on the Bureau for assistance. The projected manufactureof liquid chlorine in Peru has been aided by the Bureau Engineers' esti-mates and assistance in obtaining high-priority equipment and mate-rials. This additional source of chlorine is expected to increase immeas-urably the safety of many municipal and private water supplies alongthe Pacific coast, insuring a constant source of chlorine, and also tolighten the burden of the critical shipping situation.

Considerable advice on water supplies and their treatment and onsewage disposal has been given in Mexico, Guatemala, Costa Rica,Panama, Ecuador, Peru and Chile and close contact is being maintainedwith the sanitary engineering officials in both the ministries of publichealth and public works. Some of the larger cities which have beenaided are: San José, Costa Rica; Lima, Peru, and Santiago, Chile.Advice has been given on such subjects as hypochlorination, tile drains

21


for sewage effluents in small treatment installations, and bio-filtration.It is anticipated that as time goes on an increasingly heavy demand willbe placed on the Bureau engineering staff in this field.

Milk sanitation problems, particularly those concerned with pasteurizationplants, are also being handled by the Bureau when requested. Large pasteuriza-tion plants in Managua, Nicaragua, and Guayaquil, Ecuador, were thoroughlyinspected and recommendations for improvements made. As more responsibilityfor the safety of milk and milk products is placed on the sanitary engineers of thePan American republics, requests for Bureau aid are expected to become corre-spondingly more frequent.

Proper rubbish and garbage collection and disposal methods are being espe-cially emphasized at the moment by Bureau engineers both from their implica-tions in bubonic plague control and the curtailment of fly breeding. A trenchdisposal method for rubbish and garbage which was suggested for and recently in-stalled in Trujillo, Peru, is giving considerable promise of providing a practicaland economical solution of this important municipal sanitation problem. Othercities in both Peru and Ecuador are considering adopting similar procedures.Various bubonic plague control campaigns have been helped by the participationof sanitary engineers in market and general urban cleanup drives as well as by im-provement in rubbish and garbage disposal. Flamethrowers and cyanogas pumpshave been contiued in use as valuable aids to the campaign. Epidemiologicalinvestigations of bubonic plague are also being made in cooperation with the Bu-reau medical staff.

Educational engineering work has proceeded along several differentlines. The Bureau was extremely fortunate to be host to 17 LatinAmerican sanitary engineers during October and November of 1942and some of its engineers personally escorted these men on a tour ofrepresentative sanitary installations and projects throughout the centraland eastern United States. The guests who attended the 1942 meetingof the American Public Health Association in St. Louis and that ofState Sanitary Engineers in the same city, and many close professionaland personal ties were developed. Lectures on hospital sanitation givenby one of the Bureau engineers at the recent meeting of the Inter-American Hospital Association held in Mexico City during last Januaryhave extended the scope of sanitary engineering to include this impor-tant field. It is planned to repeat these lectures at the next meetingof the Association to be held in Lima, Peru, this year. In Peru, amonth's malaria short course designed to help train new personnel invarious categories was planned and executed through the assistance ofthe Bureau engineers. This short course will be repeated in the nearfuture and is now a permanent part of the malaria control program.

At present research is going forward on certain phases of the Onchocer-ciasis study in Guatemala, and airplane sanitation is being studied inWashington.

Objectives for the Future.-This all too brief review of present activi-ties should not complete the report of the Committee. They represent

22

SANITARY ENGINEERING

primarily a prologue. The Committee considers it necessary to empha-size the fact that the future holds important problems in the sanitaryengineering field, of which many are only partly being met and manyothers still remain to be provided for. The liberty is taken, therefore,of listing certain minimum major objectives for the future to the con-sideration of which health officers and other responsible Governmentalagents must give prompt attention.

(1) Sanitary Engineering Features of the International Transportation of Dis-ease: It is perhaps unnecessary to call attention at this Conference to the implica-tions of the speeding up of all forms of international transport and of the collateralpublic health problems which arise from these recent technological advances.Sanitary engineering perspective and activity are required on the problems of con-trol of air lines, highways, railroads, waterways, or any other form of transit acrossinternational boundaries. Within the framework of many of the conventions oninternational travel control, sanitary engineering structures and proceduresneed to be seriously scrutinized and preparation for their most effective applica-tion must be made.

(2) International Spread of Disease through Deficiencies of Sanitary Facilities:Aside from the risks attached to the transportation of disease by internationalcarriers, the Committee emphasizes the fact that we must not lose sight of therisks attached to the international traveler in the failure to provide new facilitiesor to exercise adequate sanitary control over existing facilities, in the fields of pub-lic water supply, sewage collection and disposal, insect and rodent control, garbageand waste collection and disposal, private and public housing, industrial hygieneand food and milk preparation and control.

The sins of omission, either in North America or in Central and South Americancountries, in these fields of activity may no longer carry a penalty limited by geo-graphical boundaries. The traveler from Brazil who acquires typhoid fever inIndiana is not comforted by the fact that he was traveling outside of hisown country's jurisdiction. Modern science and practice provide policies and themethods whereby international security is practicable of accomplishment in thefield of public health, even though the matter may be debated in less tangiblefields of activity.

(3) The Preparation of Suggested Minimum Sanitary Engineering Criteria:In the course of time, if the recommendations of the Committee are seriously pur-sued, suggested criteria for minimum sanitary engineering structures and activi-ties should develop in the various fields already enumerated. It is none too earlyto begin the international consideration of such criteria, not to agree upon perma-nent uniformities of practice, but to develop acceptable agreed principles. Wbenthese have stood the test of discussion and of application they are useful in extend-ing the spheres of action, both geographically and technologically.

(4) Minimum Specifications for Sanitary Engineering Products and Equip-ment: In a good many of the countries with which we are concerned, it would bedesirable and helpful to develop in the near future standard specifications for ma-terials and equipment in the chemical and mechanical fields, so that installationsand expendable materials would be purchased and used upon the basis of acceptedmodern manufacture and test. This would eliminate the risk, sometimes under-gone, of purchasing both materials and equipment which are inferior in qualityor unnecessarily expensive in cost.

(5) Exchange of Sanitary Engineering Information: The Committee stressesonce more the absolute necessity of improving international exchange of informa-

23


tion in sanitary engineering activity and international exchange of personnel.One of the greatest safeguards to the continued improvement of sanitary engineer-ing thinking and to the continued stimulation of engineering application lies in theopportunity for joint exchange of ideas.

For many sound reasons the recommendation of the Committee forthe immediate development of regional meetings of sanitary engineersboth in North and Central and South America has not been put intoeffect. The Committee reemphasizes the necessity for so doing in theimmediate future. Simultaneously with these sessions, the Pan Ameri-can Sanitary Bureau should be afforded the facilities to extend its sani-tary engineering activities both geographically and numerically.

The Committee proposes to continue its activities along the lines setforth in this report. It hopes furthermore to amplify its progressreports to the Pan American Sanitary Conferences and to the Confer-ences of Directors of Health. A significant milestone was marked bythe appointment in Rio de Janeiro for the first time of a Sanitary Engi-neering Committee. Progress since that time has been significant andthe opportunity lies ahead for extending the benefits and advantagesof sanitary engineering practice to all parts of the Americas.

24

REPORT OF THE PAN AMERICAN COMMITTEE ONEPIDEMIOLOGICAL AND VITAL STATISTICS*

Before World Wars I and II brought about a widening of the inter-national fields of cooperation, the whole of America had united in thefight against disease, with the creation in 1902 of the Pan AmericanSanitary Bureau and of the Pan American Sanitary Conferences. In-spired principally in the recognition that disease does not respect na-tional boundaries, it could be said that these organizations were pioneersof the vast international public health mechanisms that were soon to beset up on a larger scale on the continent of Europe with the creationfirst of the International Office of Public Health of Paris and then ofthe Health Organization of the League of Nations. Thus, through theteachings of hygiene, and facing the fact that in public health matters acommon front was indispensable if the health of the peoples of the Ameri-cas was to be preserved, the continentalization and later the universali-zation of public health activities were attained. Special stress is laid onthese facts because very probably it was through the weight of the im-portance conceded to epidemiological intelligence that these organiza-tions were made possible. The very first words of the Pan AmericanSanitary Code, which by the way was the first Pan American agreementto win the ratification of all the American Republics, read as follows:

"The objects of this code are: The prevention of theintqrnationalspreadof communicable infections...; the promotion of cooprative measuresfor the prevention of the introduction and spread of diseases into andfrom the territories of the signatory Governments.. .; the standardiza-tion of the collection of morbidity and mortality statistics...; thestimulation of the mutual interchange of information... etc." Every-one of them directly connected with the field of epidemiologi~\al statistics.

It must be confessed that in daily practice, during the\ 20 years ofexistence of the Code and therefore of the obligations imposed by it onthe signatory Governments, it has not always been possible to attainits full adherence. In recent years, and in view of the bigger potentialmenace of the international spread of diseases brought about by thepresent War, the.Pan American Sanitary Bureau and particularly itsDirector, have constantly tried to correct this incomplete fulfillmentwhich in some cases has been due to lack of epidemiological informationin the countries themselves, but in others has been caused by preventablefactors.

There have been very few subjects, if any, on which a larger numberof resolutions ,has been approved at the Pan American sanitary con-ferences than those related to the reporting of communicable diseases

· Submitted by Mr. R. H. Martfnez, Secretary of the Committee, to the Conference\of NationalDirectors of Health in Washington, D. C., on April 22-29, 1944.

25


and biostatistics. At the last one, the XI held in Rio, a resolution wasadopted recommending the "constitution in the Pan American SanitaryBureau of a committee for the standardization of biostatistical standardsand for the coordination of efforts directed to the solution of biostatisticalproblems of general interest to the American countries." In harmonywith that resolution, in August 1943 the Pan American Sanitary Bureaucreated the Pan American Committee on Epidemiological and VitalStatistics, the primary purposes of which are (1) to improve the inter-national reporting'of communicable diseases, and (2) contribute to thestandardization of biostatistical procedures. The Committee has beenprovisionally formed of the following members: Dr. A. A. Moll, Secre-tary of the Pan American Sanitary Bureau; Dr. Selwyn D. Collins,Chief Statistician of the United States Public Health Service; Dr. ClarkH. Yeager, Chief of the Medical Section of the Division of Health andSanitation of the Office of the Coordinator of Inter-American Affairs;Dr. Elbridge Sibley, of the Division of Statistical Standards of the U. S.Budget Bureau,, representing the Inter-American Statistical Institute,with Miss Clara Councell, Medical Research Officer of the Office of theCoordinator of Inter-American Affairs, acting as liaison officer, and Mr.Rafael H. Martinez, of the Pan American Sanitary Bureau, as Secretary.

The Committee met for the first time in August 1943, when it recom-mended a project calling for the appointment, with the approval of theNational DirectOrs of Health, of a statistical representative in each oneof the Nationa~ Public Health Services of the American Republics.These representatives were to be expected to send to the Pan AmericanSanitary Bureáu, by the quickest suitable route, data on the incidenceand mortality from communicable diseases and on biostatistics in gen-eral. With ihese representatives in Latin America, the Committee wasthus to acqUire a Pan American character. With the information re-ceived, the Pan American Sanitary Bureau, besides its Weekly Epi-demiological Report, was to prepare a Monthly Biostatistical andEpidemiological Report with more detailed information, both of thesereports fór air mail distribution. The project which, thanks to thegenerous 'cooperation of the Office of the Coordinator of Inter-AmericanAffairs, became a reality last April, also includes the translation intoSpanish of a Manual for Coding Causes of Illness prepared by the Na-tional Institute of Health of the U. S. Public Health Service with thecooperation of the U. S. Census Bureau, the Hospital and School ofPublic Health of Johns Hopkins and the Mayo Clinic. This Manualcontains thousands of terms or morbid manifestations or conditionsarrangedlin alphabetical order with their reference code numbers in theList of Diagnosis Categories for Morbidity Tabulations also prepared bythe same organization and already translated by the Pan AmericanSanitary Bureau (Publication No. 164). With the application of this

26

VITAL STATISTICS

Manual a higher degree of uniformity will be obtained in assigning thediagnosis to the proper category in the List and a great step will havebeen taken toward the standardization of one of the most importantphases of biostatistics. In order to obtain a text of maximum PanAmerican application, it has been deemed desirable to appoint a Com-mittee of 4 or 5 of the statistical representatives of the Pan AmericanCommittee on Epidemiological and Vital Statistics to complement theManual with nosological terms of more common usage in Latin America,which may be missing in the Manual.

Listed below are some of the practical results derived so far in thefew weeks of execution of the project.

1. Seventeen representatives have already been appointed.2. The reports received from the representatives in the first month of oper-

ation of the project constitute the most extensive collection of such reportsever received by the Bureau in a similar length of time.

3. The quickest forms of communication were employed to transmit the,reports to the Pan American Sanitary Bureau, namely the telegraph andair mail.

4. The first number of the Monthly Biostatistical and Epidemiological Reporthas been issued and distributed by air mail; the second report is underpreparation. It is believed that with the preparation of the Monthly Re-port and its rapid distribution, it will be possible to place the data in thehands of the interested parties in the American countries with a saving ofat least 3 months over the method previously employed-time being aprimary consideration in epidemiological matters.

5. During the month of March and the first half of April, the Pan AmericanSanitary Bureau received epidemiological reports directly by air mail from32 countries, and indirectly by telegraph and through the good offices ofthe Health Organization of the League of Nations in Switzerland, theInternational Office of Public Health of Paris and the Ministry of PublicHealth of England, from another 50 non-American countries. Not in-cluded in these figures are an additional number of countries on which theU. S. Public Health Service keeps the Pan American Sanitary Bureauinformed as to serious epidemic outbreaks, the data in these cases pro-ceeding from diplomatic sources.

6. The Weekly and Monthly reports of the Pan American Sanitary Bureauare sent by air mail to some 35 countries, and by cablegram to the Leagueof Nations Health Organization.

7. An investigation conducted revealed that these reports are reaching desti-nation usually in less than 12 days, and in the case of the American coun-tries in an average of 2 to 6 days.

Special emphasis should be laid on the enthusiasm and interest thatthis project has stirred in the epidemiological and biostatistical servicesof the National Departments of Public Health, enthusiasm which maypossibly rebound to the improvement of such services. In one countryfor example, the reporting of cases of communicable diseases from theinterior of the country to the central oflices is to be made by the tele-graphic medium instead of regular mail; in another country steps have

27

28 PAN AMERICAN SANITARY BUREAU

already been taken to expedite and improve reporting. In severalothers we have been informed that measures are being considered toimprove reporting. These facts, in the opinion of the Pan AmericanCommittee on Epidemiological and Vital Statistics constitute in them-selves concrete proofs of the practical value of this work.

The facts herein mentioned represent only the fundamental basis onwhich a more robust mechanism can be erected with the cooperation ofthe National Health Authorities for the attainment of the desired goalin the field of international vital and epidemiological statistics, with itscontributory influence in the fight against disease.

As soon as the circumstances of the present War may permit, it isplanned to send out this epidemiological information and other im-portant pertinent public health facts by radio, weekly, bi-weekly or asoften as may be necessary, in what might be referred to as the "PanAmerican public health hour."

PUBLICACIONES DISPONIBLES DE LA OFICINA SANITARIAPANAMERICANA

AVAILABLErPUBLICATIONS OF THES PAN AMERICAN SANITARYBUREAU

Actas de la Tercera Conferencia Sanitaria Internacional de las Repúblicas Americanas. Espafol.Actas de la Cuarta Conferencia Sanitaria Internacional de las Repúblicas Americanas. Ingles y espafiolActas de la Quinta Conferencia Sanitaria Internacional de las Repúblicas Americanas. Inglés y espafiolActas de la Sexta Conferencia Sanitaria Internacional de las Repúblicas Americanas. Español.Actas de la Séptima Conferencia Sanitaria Panamericana. Inglés y español.Actas de la Octava Conferencia Sanitaria Panamericana. Espafiol.No. 1-Prevención de la Enfermedades Transmisibles. 60 páginas.No. 3-Higiene Pre-natal. 7 páginas.No. 5-Ordenanza Modelo para Leche. 11 páginas.No. 7-Organización del Servicio de Sanidad Pública de los Estados Unidos. 26 páginasNo. 9-La Profilaxis del Bocio Endémico. 10 páginas.No. 19-Colecta, Examen e Identifación de las Pulgas Murinas. 11 páginas.No. 23-Meningitis Cerebroespinal Epidémica (Meningocócica). 4 páginas.No. 26-Tifoidea: Su Causa y Profilaxia. 4 páginas.No. 30-Tratamiento del Paludismo. 4 páginas.No. 37-El Interrogatorio en el Diagnóstico Precoz de la Tuberculosis Pulmonar. 3 páginas.No. 43-Código Sanitario Panamericano. 23 páginas.No. 45-La Declaración Obligatoria del Embarazo. 10 páginas.No. 46-La Difteria en el Trópico. 15 páginas.No. 47-Los Censos en Sanidad yen Epidemiologla. 13 páginas.No. 48-Higiene Comunal para el Pre-escolar. 5 páginas.No. 49-El Diagnóstico de la Fiebre Amarilla. 14 páginas.No. 50-Acta Final, II Conferencia Panamericana de Directores Nacionales de Sanidad. 16 páginas.No. 51-Milk. 8 pages.No. 52-Summaryof Proceedings, IIPanAmerican Conferenceof National Directorsof Health. 14 pagesNo. 53-Vacunación Antidiftérica. 8 páginas.No. 55-A Lucta Anti-Larvaria no Impaludismo. 6 páginas.No. 57-Diagnóstico Retrospectivo de la Fiebre Amarilla. 6 páginas.No. 61-Immunización Profiláctica de los Recién Nacidos con BCG. 22 páginas.No. 62-Epidemiología de la Lepra. 5 páginas.No. 65--La Higiene Mental. 11 páginas.No. 82-Narcomanla. 46 páginas.No. 88-Antirratización de los Buques. 40 páginas.No. 90-Control de las Enfermedades Transmisibles. 70 páginas.No. 97-Acta Final,'Novena Conferencia Sanitaria Panamericana. 20 páginas.No. 98-El Problema de la Fiebre Amarilla en América. 10 páginas.No. 99-Profilaxia de la Fiebre Amarilla. 6 páginas.No. 101-Ninth Pan American Sanitary Conference (Final Act). 8 pages.No. 102-El Saneamiento del Suelo. 17 páginas.No. 103-Report of the Director of the Pan American Sanitary Bureau to the Ninth Pan American Sani.

tary Conference. 8 pages.No. 104-Profilaxia y dominio del paludismo. 24 páginas.No. 105-Fumigación de buques. 14 páginas.No. 108-Las Repúblicas Americanas ante las Convenciones Internacionales de Sanidad. 5 páginas.No. 109-La Lucha Antivenérea. 27 páginas.No. 110-Third Pan American Conference of National Directors of Health: Summary of Proceedingsa

10 pages.No. 111-Venenos Antirrata. 4 páginas.No. 112-Tratamiento Anti-Lepr6tico. 14 páginas.No. 113-Pautas de'Organizaci6n Sanitaria. 12 páginas.No. 118-Servigo de Peste. 6 páginas.No. 121-Actas de la Tercera Conferencia Panamericana de Directores Nacionales de Sanidad. 396

páginas.No. 127-Lepra: Epidemiologfa-Clasificaci6n-Tratamiento. 17 páginas.No. 128-A Classificaéo da Lepra. 5 páginas.No. 129-Final Act: Tenth Pan American Sanitary Conference. 13 pages.No. 130-Dixiéme Conference Sanitaire Panaméricaine: Acte Final. 20 pages.No. 131-X Conferéncia Sanitaria Panamericana: Ata Final. 12 páginas.No. 132-Modelos de Certificados de Defunción, de Nacimiento Viable, y de Defunción Fetal. 4 páginas.No. 134-Los Preventorios en la Lepra. 8 páginas.

No. 135-Proyecto de Escalafón Sanitario. 12 páginas.No. 137-Nomenclatura Internacional de las Causa de Muerte. 25 páginas.No. 139-Mate. 8 páginas.No. 141-Sociedades e Instituciones Cientificas de la América Latina (Scientific Societies and Institutions

in Latin America). 50 páginas.No. 142-Demografia de las Repúblicas Americanas. 16 páginas.No. 143-Educación Sexual Destinada a los Padres. 9 páginas.No. 145-Lo que debemos saber sobre Cáncer. 6 páginas.No. 147-IV Conferencia Panamericana de Directores Nacionales de Sanidad: Acta Final. 9 páginas.No. 148-The Pan American Sanitary Bureau and ita Cooperative Work in the Improvement of Milk

Supplies. 4 pages.No. 149-Half a Century of Medical and Public Health Progress. 20 pages.No. 165-Medio Siglo de Adelanto en Medicina y Sanidad. 22 páginas.No. 151-IV Pan American Conference of National Directors of Health (Final Act). 8 pages.No. 153-Annual Report of the Director of the Pan American Sanitary Bureau: 1939-1940. 34 pages.No. 154-Reacción a la Tuberculina. 6 páginas.No. 155-Informe Anual del Director de la Oficina Sanitaria Panamericana: 1939-1940. 39 páginas.No. 157-Epitome del Segundo Suplemento (1939) de la Farmacopea E. U. XI. 20 páginas.No. 159-Some Pan American Pioneers in Public Health. 5 pages.No. 161-Indices Sanitarios Panamericanos. 3 páginas.No. 162-Conferencia Panamericana de Directores Nacionales de Sanidad: Resumen de sus labores.

29 páginas.No. 163-Huertos Escolares. 7 pAginas.No. 164-Clave Diagnóstica para la Clasificación en Columna (tabulación) de las Causas de Morbidad.

18 páginas.No. 165-Contribuciones al Estudio de la Peste Bubónica en el Nordeste del Brasil. 331 páginas.No. 166-Health and Living Conditions in Latin America. 11 pages.No. 167-The Work oí the Pan American Sanitary Bureau in Relation to Child Welfare. 4 pages.No. 168-La Enseflanza Médica en Estados Unidos. 22 páginas.No. 169-El Lanzallamas en la Lucha Antipestosa. 9 páginas.No. 170-El Entierro de la Basura bajo un Recubrimiento Eficaz en Cristóbal, Zona del Canal. 11

páginas.No. 171-Fourth Pan American Conference of National Directors of Health; Resumé. 26 pages.No. 172-Pautas Minimas para el Saneamiento de las Minas del Perú en lo Relativo a Viviendas. 8

páginas.No. 173-La Fiebre Amarilla en las Américas. 15 páginas.No. 174-Diagnóstico y Tratamiento de Ciertas Afecciones de los Trópicos. 12 páginas.No. 175-Housing and Hospital Projects of Latin American Social Security Systems. 15 pages:No. 177-Public Health in the Americas. 68 pages.No. 178-Tratamiento de las Quemaduras. 4 páginas.No. 179-Informe Anual del Director de la Oficina Sanitaria Panamericana: 1940-1941. 42 páginasNo. 180-La mosca. 9 páginas.No. 181-Child Nutrition in Latin America. 17 pages.No. 182-Tratamiento de las Afecciones Venéreas en el Ejército de Estados Unidos. 9 páginas.No. 183-Técnicas y Procedimientos para las Encuestas o Censos Dietéticos. 6 páginas.No. 184-Tratamiento de las heridas de guerra. 4 páginas.No. 185-Alphabetical List of Medical and Public Health Journals of Latin America. (Lista Alfabética

de las Revistas de Medicina, incluso Sanidad y Cienciss Aliadas, de la América Latina). 60pages.

No. 186--Manual de Bromatologia. 611 páginas.No. 187-Reglamento del Servicio Nacional Antipestoso del Perú. 3 páginas.No. 188-The Wild Fire (Pemphigus foliaceus) of Brazsil. 13 pages.No. 189-Hospital Development in Latin America. 10 pages.No. 190-La Sanidad en las Américas. 95 páginas.No. 191-American Hospitals & Latin American Interns. 9 pages.No. 192-Actas de la IV Conferencia de Directores Nacionales de Salubridad. 573 paginas.No. 193-Pan American Sanitary Code. 23 pages.

Y No. 194-Annual Report of the Director of the Pan American Sanitary Bureau: 1941-1942. 45 pagas.Y No. 195--Informe Biodemográfico y Epidemiológico de las Américas. 84 páginas.

No. 197-Paludismo en Algunas de las Repúblicas de America. 44 páginas.'-'No. 198-Eleventh Pan American Sanitary Conference: Final Act. 9 pages.v. No. 199-Classified List of Medical & Public Health Journals of Latin America. (Revision of Pub.

No. 152) 68 pages.No. 200-El Manejo de las Plantas de Tratamiento de Aguas Negras. 35 páginas.No. 201-Tuberculosis: Normas para el Diagnóstico. 25 páginas.No. 202-Recomendaciones de la Comisión Panamericana de Malaria. 4 páginas.No. 203-Malaria Control Activities of the Pan American Sanitary Bureau. 8 pages.No. 204-Annual Report of the Director of the Pan American Sanitary Bureau: 1942-1943. 40 pages.

,'No. 205-Undécima Conferencia Sanitaria Panamericana. Acta Final. 9 páginas.No. 206-Plan Práctico para el Tratamiento de las Micosis Superficiales. 9 páginas.No. 207-The Pan American Sanitary Bureau and its Work in the Field of Maternal and Child Welfare.

3 pages.No. 2t8-Técnicas de Inmunización en Estados Unidos: Ejército, Servicio de Sanidad Pública. 8

páginas.' No. 209-Prevención y Tratamiento del Ofidismo. 6 páginas.

J No. 210-Recientes Adelantos en Sanidad y Medicina en las Américas. (Recent Public Health and Med-

ical Progress in the Americas). 92 páginas.6 No. 211-Terminologfa Panamericana del Paludismo. 54 páginas.

-w No. 212-Inter-American Conference of Professors of Hygiene. 143 pages.- No. 213-Manual de Higiene Industrial.iA' No. 214-Scientific Institutions in Latin America-Part II. 24 pages.

s No. 215-Control de las Enfermedades Trasmisibles. 160 páginas."No. 216-Técnicas de las Encuestas de Alimentación. 98 páginas.

No. 217-Organización de los Servicios de Bioestadfstica de Chile, Estados Unidos y México. 31 páginas.No. 218-Proceedings of the First Inter-American Conference on Health Education.No. 219-Health Precautions for Visitors to the Tropics. 7 pages.

,.-No. 220-Annual Report of the Director of the Pan American Sanitary Bureau: 1943-1944.No. 221-V Conferencia Panamericana de Directores Nacionales de Sanidad (Acta Final). 42 páginas.No. 222-V Pan American Conference of National Directors of Health (Final Act). 28 pages.

THE PAN AMERICAN SANITARY BUREAU is an independent internationalpublic health organization. It was created by 'the Second International

American Conference (1901-1902), organized by the First Pan American Sar-;+rvConference (1902), and reorganized by the (1920). It is goverrl 'Directing Council elected, together with the Director, at each Pan Am-,Sanitary Conference. The Bureau is supported by annual quotas contribute -rata by all the American Republics. It is interested primarily in the preventionof the international spread of communicable diseases, and also in the maintenanceand improvement of the health of the people of the 21 American Republics. Underthe provisions of the Pan American Sanitary Code (1924), it has become the centerof coordination and information in the field of public health, in the AmericanRepublics. It also acts as a consulting body at the request of national healthauthorities, carries on epidemiological and scientific studies, and publishes amonthly Bulletin, as well as other educational material. Pan American HealthDay is celebrated annually on December 2 in all American Republics. Addressall correspondence to the Director of the Pan American Sanitary Bureau,Washington, D. C.

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