TASK FORCE ON HEALTH AT THE MINISTERIAL LEVEL

TASK FORCE ON HEALTH AT THE

MINISTERIAL LEVEL

Washington, D.C.

15-20 April 1963

PAN AMERICAN HEALTH ORGANIZATIONPan American Sanitary Bureau, Regional Office of the

WORLD HEALTH ORGANIZATIO0N

TASK FORCE ON HEALTH AT THE

MINISTERIAL LEVEL

Washington, D.C.

15-20 April 1963

Official Document No. 51

PAN AMERICAN HEALTH ORGANIZATIONPan American Sanitary Bureau, Regional Office of the

WORLD HEALTH ORGANIZATION1501 New Hampshire Avenue, N.W.

Washington, D. C. 20036

April 1964

p1

PREFACE

This volume contains an historic document, historic because of the ideasit sets forth and the experience it reflects; because of the import of thoseideas for the nations of our Hemisphere, and the authority of those thatexpound them; because of the pledge to put those ideas into practice thatthe signature of that document represents; and because of the importanceof those ideas in the economic and cultural panorama of our time. Thatdocument is the Final Report of the Meeting of Ministers of Health, whichserved as the Task Force on Health in accordance with Resolution A.4 ofthe Charter of Punta del Este.

Its contents reveal the prime reason for the Meeting-to examine theintrinsic purposes of health activities and their future perspectives withinthe general process of development, to which the nations of the Americashave resolved to devote themselves with increasing vigor.

Experts from the signatory countries of the Charter, presided over by theMinisters of Health of the majority of those countries, met in Washingtonfrom 15 to 20 April 1963. The Pan American Sanitary Bureau was given theresponsibility for organizing and facilitating the discussions of some onehundred health experts. For this purpose, it convened Advisory Committeesprior to the Meeting of the Task Force, and the working documents preparedby those Committees, together with those drawn up by the staff of the PanAmerican Sanitary Bureau, served as the basis for an examination of thescope and importance of the problems discussed and the adoption of practicalmeasures for their solution. They made it possible for the Task Force todefine the current health situation in the Americas and to forecast its future,as well as to examine the points to which efforts should be directed toachieve the goals of the Alliance for Progress.

During the plenary sessions, the Ministers presented their views on thehealth goals of the Charter of Punta del Este and voiced their opinions onthe possibility of carrying out the Ten-Year Public Health Program men-tioned in Resolution A.2. They highlighted the basic problems; the criteriafor deciding on their priority in each country; general and specific measuresfor solving them; and the meaning of health as an investment for promotingeconomic progress and social development. Their statements depicted thepresent situation in the health field, in both its positive and its negativeaspects, and delineated what remains to be done and how to do it. A sum-mary of the leading ideas of the addresses of the Ministers is to be foundin the first four chapters of the Final Report.

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In theory, the fundamental problem of the technicians will be to showthe significance for development of each program in particular; this involvescompetition for the assignment of scanty resources to meet growing andimperious needs. They will have to defend the thesis of health as an invest-ment; they will have to show that the be-all and end-all of economic systemsis man; they will have to offer evidence of the contribution, in terms of bothnatural wealth and increased productivity, which health programs make todevelopment and welfare. All this without losing sight of the fact that manis the synthesis of all the efforts of society and that it is a collective dutyto respect his dignity, his sense of values, and his cultural characteristics.

Two committees, organized by the Meeting, worked simultaneously. Thefirst examined prevalent problems such as communicable diseases, sanitation,nutrition, and the general objective, namely, to increase the average lifeexpectancy at birth by five years during the decade. The second committeedealt with the fundamental tools for achieving the goals of health care,such as planning; training of professional and auxiliary personnel; organiza-tion and administration of health services; and research. Each theme wassubjected to a thorough and careful analysis based on the information andideas contained in the documents prepared by the Advisory Committees andthe technical staff of the Pan American Sanitary Bureau. For each subject,the committees made both theoretical and practical recommendations which,amended where applicable, were approved by the Meeting in plenary session.These are to be found in the second half of the Final Report. The measuresproposed are, of course, regional in character and need to be translated intoterms appropriate to each country, depending on the characteristics of theproblems and possible solutions. By and large, the examination may besaid to have been made with an eye to the future, in the light of the present,so that emphasis was given to what remains to be done rather than to thesuccesses already achieved. The Meeting was aware that there was anundertaking to be accomplished within a period of ten years, and that inorder to make progress it was essential to determine the situation in eachcountry, the additional resources needed, and means and methods of financ-ing. Hence the importance of the proposals concerning the tools whichtechnicians use to protect, promote, and restore health. In the Americastoday the major communicable diseases, namely, the quarantinable diseases,have disappeared or are disappearing and among the factors contributingto morbidity and mortality are the acute and chronic infectious diseases,poor sanitation, malnutrition, insanitary housing, illiteracy, and a very lowper-capita income.

Most of these diseases can be overcome by proven methods of preventionand treatment. And since the great urban centers already show, as far ashealth is concerned, some of the features of industrial societies, is it not clearthat the application of known techniques, the organization of services, theformulation of programs, the education and training of professional and

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auxiliary workers, and research will also be of help to the Americas inattaining the objectives of the Charter of Punta del Este?

Justifiable priority has been assigned to the preparation of national healthplans. The plans and their programs will facilitate the allocation of domesticand external resources, for the purpose of achieving proposed goals; theywill provide the technicians working for the social development and economicprogress of each country with a common language and thus promote theirmutual understanding; and they will give each sector its own perspectivewithin the over-all plan. Hence the urgency of preparing more health plan-ners and of spreading a knowledge of simple methods, so as to enable thetechnicians of each country to collaborate with the planners in collectingdata, assigning priorities, and formulating plans.

Among the recommendations of the Task Force, special mention should bemade of that relating to the establishment of a Rural Welfare Fund, whosepurpose is to supplement what organized communities need in order to satisfyessential civic needs. The Meeting was aware of the fact that 50 per cent ofthe population of Latin America live in rural areas and that their level ofliving is low compared with that of the inhabitants of the more populatedcenters. Moreover, the importance of agricultural development for theeconomy of the Hemisphere, and the fact that about 50 per cent of the laborforce is engaged in agriculture, shows how primitive are the methods used.More important than funds is the communities' desire to help themselves bycontributing both labor and money to specific projects. The Pan AmericanSanitary Bureau is to make a concrete proposal to the Governments on howto translate the Rural Welfare Fund into reality.

Another proposal made was to create a Latin American common marketfor biological products, the idea being to improve the quality of thoseproducts and increase the production of them in certain countries, and thusestablish standards for a healthy interchange for a humanitarian purpose.

What is not included in the Final Report is as important as what iswritten therein. Since the establishment of the International SanitaryBureau-today known as the Pan American Sanitary Bureau-in December1902, the Meeting of the Task Force marked the first time in this centurythat distinguished experts of the Americas convened to discuss purely tech-nical matters, in all of which progress has been sustained. There could nothave been a more favorable moment. The Hemisphere is pervaded with aspirit of renewal, of transforming expectations and hopes into the reality ofwell-being. It was this spirit that animated the Meeting of the Task Force,and stimulated official and extra-official exchanges of ideas and of experiencebetween Ministers, with a view to averting errors. The desire of the Ministersand the Governments to give direct assistance to one another furtherstrengthened the solidarity of the Americas, which because of their culture

v

and the worth of their people must play their appointed role in the concertof nations.

The Final Declaration is not only a simple expression of faith; it gave thefollowing answer to the basic question which the Task Force met to dealwith, namely: Can the Ten-Year Public Health Program of the Alliance forProgress be put into practice?

"From this analysis, we have concluded that the Ten-Year Public HealthProgram of the Alliance for Progress can be carried out, provided its ob-jectives are integrated in a rational way with the other goals that ourcountries propose to reach and that the potential resources of each and everyone of our countries, and our wills, are mobilized to the full in the serviceof a higher ideal: the attainment of well-being for the benefit of all thepeople of America.

"This noble task must be accomplished for the sake of the dignity of thepeople of America, in whom resides the destiny of the Hemisphere at thissingular hour in history."

DR. ABRAHAM HORWITZDirector, Pan American Sanitary Bureau

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CONTENTS

PageFinal Report

I. Terms of Reference ............................................... 3II. The Role of Health in the Economic and Social Development of the

Americas .................................. ................. 3III. The Principal Health Problems of the Americas ...................... 5IV. Criteria for Establishing Priorities in Health Problems ................ 6V. The Present Health Situation in the Americas and the Outlook for the

Future ...................................................... 7VI. Measures Recommended for the Implementation of the Ten-Year Public

Health Program of the Alliance for Progress ............. 13

A. Specific Measures .............................................. 14A.1 Malaria Eradication ...................................... 14A.2 Tuberculosis Control ...................................... 16A.3 Smallpox Eradication ..................................... 17A.4 Chagas' Disease .......................................... 18A.5 Nutrition ................................................ 19A.6 Environmental Sanitation ................................. 20

B. General MeasuresB.1 National Planning for Health ............................... 22B.2 Improvement of Health Services ............................ 24B.3 Education and Training .................................... 27B.4 Research ............................................ ... 30B.5 Increase in Life Expectancy at Birth by a Minimum of Five

Years during the Decade ................................. 31

VII. Recommendations ................................................ 32

A.1 Malaria Eradication .......................................... 32A.2 Tuberculosis ................................................ 33A.3 Smallpox Eradication ........................................ 33A.4 Chagas' Disease ............................................. 33A.5 Nutrition ................................................... 34A.6 Environmental Sanitation ..................................... 34B.1 National Planning for Health .................................. 36B.2 Improvement of Health Services ............................... 37B.3 Education and Training of Professional Health Personnel ......... 38B.4 Research .................................................... 39B.5 Increase in Life Expectancy at Birth by a Minimum of Five Years

during the Decade ....................................... 39C.1 Latin American Common Market for Biological Products ......... 40C.2 Quality and Cost of Essential Drugs ........................... 40C.3 Role of Women in the Ten-Year Public Health Program of the

Alliance for Progress ..................................... 41C.4 National Committees for the Alliance for Progress ............... 41C.5 Coordination with International Organizations .................... 41

VIII. Final Declaration ................................................ 41

Addresses by the Participants

Address by the Secretary General of the Organization of American States,Dr. José A. Mora ................................................... 47

vii

CONTENTS (cont.)

PageMessage of Welcome from the President of the United States of America ..... 55Address by the President of the Inter-American Development Bank, Mr. Felipe

Herrera ................................................ 56Address by the Secretary of Health and Welfare of Mexico, Dr. José Alvarez

Amézquita, on behalf of the Ministers ................................ 61Statement by the Director of the Pan American Sanitary Bureau, Dr. Abraham

Horwitz, on the Organization and Development of the Meeting .......... 63EcUADOR-Address by the Minister of Social Welfare, Labor, and Health ..... 66ARGnNTINA-Address by the Minister of Social Welfare and Public Health .... 69UNMrrD STATES OF AMEiRcA-Address by the Surgeon General of the Public

Health Service ..................................................... 74HoNDURAs-Address by the Undersecretary of State for Public Health and

Social Welfare ..................................................... 79URuGtUAY-Address by the Minister of Public Health ....................... 84PERu-Address by the Minister of Public Health and Social Welfare ......... 87BRAzI,-Address by the Minister of Health ............................... 91CHILm-Address by the Minister of Public Health ......................... 97BoLVA-Address by the Director of the National Public Health Service ..... 100PARAGUAY-Address by the Minister of Public Health and Social Welfare..... 102GUATEMALA-Address by the Representative of the Minister of Public Health

and Social Welfare .................................................. 107MExico-Address by the Secretary of Health and Welfare .................. 111DOMINICAN REPUBLIC-Address by the Secretary of State for Health and Social

Welfare ................................................ 118EL SALvADOR-Address by the Minister of Public Health and Social Welfare... 121COSTA RIcA-Address by the Minister of Public Health ...................... 126CoLOMBIA-Address by the Minister of Public Health ....................... 130PANAMA-Address by the Minister of Labor, Social Welfare, and Public Health. 134VENnzuELA-Address by the Minister of Health and Social Welfare ......... 136NICAUiGuA-Address by the Deputy Minister of Public Health .............. 142

Annexes

ANNEX 1. Officers of the Meeting and of the Committees ................... 151ANNEX 2. List of Participants ........................................... 152ANNEX 3. Agenda ..................................................... 156ANNiX 4. Program of Sessions .......................................... 158

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Final Report

TASK FORCE ON HEALTH AT THE MINISTERIAL LEVEL

Final Report

I. TERMS OF REFERENCE

The Charter of Punta del Este, in Reso-lution A.4, recommends that the SecretaryGeneral of the Organization of AmericanStates establish Task Forces to undertakeinvestigations and studies of the most im-portant problems in various areas of eco-nomic and social development, and to makerecommendations for their solution "thatmay serve as a basis for the Member Statesin preparing their national developmentprograms." In the matter of health, theresolution recommends that the pertinentTask Force, organized through the PanAmerican Sanitary Bureau, "appraise prev-alent problems and suggest general linesof action of immediate effect relating to:the control or eradication of communicablediseases; sanitation, particularly water sup-ply and sewage disposal; reduction of in-fant mortality, especially among the new-born; and improvement of nutrition; andthat it also recommend actions for educa-tion and training of personnel and improve-ment of health services" (Resolution A.4.4).

In view of the variety of problems men-tioned in this resolution, the Pan AmericanSanitary Bureau first convened a series ofAdvisory Groups composed of experts from

the Americas to examine the present statusof each problem and suggest practical meas-ures for achieving the goals of the Charterof Punta del Este, in particular the Ten-Year Public Health Program set forth inResolution A.2. The reports of these com-mittees, as well as those prepared by thetechnical staff of the Bureau, were madeavailable to the Governments and consti-tuted valuable background material for theorganization of the Task Force on Health.It was deemed advisable for the Task Forceto be at the ministerial level in order toharmonize the opinions of those who areresponsible for the health of the Americas.

The Task Force on Health, composed ofthe Ministers of Health of all the signatoryGovernments of the Charter of Punta delEste, or their representatives, met at theInternational Inn in Washington, D. C.,from 15 to 20 April 1963. The list of partici-pants appears in Annex 2 (page 152). TheTask Force held eight plenary sessions, foursessions of Committee I, and three sessionsof Committee II, and considered the itemscontained in the agenda (Annex 3, page 156)as approved at the second plenary session.

II. THE ROLE OF HEALTH IN THE ECONOMIC AND SOCIALDEVELOPMENT OF THE AMERICAS

The Act of Bogotá and the Charter ofPunta del Este reflect the determination ofthe Governments of the Americas to unitein a common effort to accelerate social wel-fare and economic growth simultaneously.

3

This decision emphasizes that the funda-mental aim of development is the well-beingresulting from a higher level of living. Analliance for progress is being born, progressbeing understood to mean the enhancement

4 Task Force on Health

of man's ability to improve his social en-vironment and to live in harmony with it.The measures proposed for the attainmentof that end are those aimed at expandingthe economy and at increasing both produc-tion and productivity; in social matters,measures for the improvement of health,education, housing, nutrition, work, andrecreation are most important. It is gener-ally agreed that, in the allocation of na-tional and external resources, economic de-velopment and social progress should beequitably treated, and needs and resourcesshould be matched in a single programaimed at definite targets.

A healthy and active population is es-sential for economic growth and social prog-ress. Health is therefore a basic componentof development and of the standard of liv-ing. Resources devoted to health care arean investment, a source of productivity, notan expenditure. The return on that invest-ment can be measured in terms of the im-proved capacity of the members of a com-munity to create, produce, invest, and con-sume. It may likewise be measured by thegreater yield obtained from natural re-sources as a result of health work.

Seen from another viewpoint, improve-ment of health implies a raising of livingstandards that basically benefits the low-income groups of our communities. Conse-quently, it contributes notably to the at-tainment of one of the most important goalsof the development process, that is, to bringabout a better distribution of an increasingreal income.

It is fitting to recall that internationalcooperation in the field of health was ini-tiated for the purpose of reducing the lossesdue to the great epidemic diseases that wererestricting commercial exchanges betweencountries. The International Sanitary Bu-reau-now the Pan American SanitaryBureau-was established toward the end of1902 as an agency to advise Governmentson such health matters. The combination of

a humanitarian purpose with an economicone shows the vision of the statesmen andexperts of that time, and is an example, aharbinger, of the intimate and reciprocalrelation between health and development.

At the present time large-scale epidemicsoccur only exceptionally. Health problemstend to reflect the characteristics of eachenvironment and the influence of that 'en-vironment on the human beings that live init. Health work, which has not always beenconsidered in the light of its reciprocal re-lation to other social phenomena, must beregarded as'peculiar to each community,with specific techniques for the preventionand cure of diseases, adapted to the socialand cultural conditions of the population.As yet, there has been no integration of ac-tivities either in the services or at the levelof the theoretical work unit, i.e., the family.Only a very small attempt at coordinationhas been observed. In any event, if it hasbeen achieved in any social environment, ithas been done without relation to the otheractivities that generate community welfare.Nor has any careful attention been given tobalancing needs against resources on a na-tional basis. Health budgets have not in-cluded the essential activities for achievingdefinite objectives, but have been only alist of probable expenditures unrelated to aprogram of work. Because of this, the totalinvestment in services of this type has notreached its proper proportion of the nationalincome.

Moreover, the health investment is ut-terly inferior to the manifest needs in all thecountries. For this reason, a substantial andprogressive increase in the health budgets isrecommended, in accordance with rationallyformulated plans. It is recognized that, in

some countries, such plans will require an

investment of at least twice the currentlevel of support.

Only in recent years has the idea beenmaking headway that advances in healthcome to a standstill and retrogress after a

Final Report 5

time if economic growth is not fast enoughto finance activities intended to meet thebasic needs of the population. There is anawareness today that health programs arepart of-not separate from-general devel-opment planning. This is the method recom-mended in the Charter of Punta del Este. Intheory and in practice, a plan should bebased on social needs and the necessary eco-nomic resources. When the latter are in-sufficient, an order of priority must be es-tablished among the problems in each sec-tor. This involves setting up criteria forassigning priorities to each social activity,which will facilitate the allocation of re-sources within the general developmentplan. As the economy expands, the nationalresources will be redistributed in accordancewith these priorities, and these, in turn, willbe translated into specific objectives to beattained within a specified time.

Since health is defined as a state of com-plete physical, mental, and social well-being,we interpret it, in the light of the Charterof Punta del Este, as a fundamental factorin development. This proposition reaffirmsthat man is the sum of all the efforts of asociety, the object, the end, and the measureof all things; and that it is therefore of the

utmost importance to improve his livingconditions and ensure his personal, material,and moral well-being. Health has come tobe regarded as a "right," on a par with theother basic human rights. The thesis thatsociety is responsible for the health of itsmembers and should actively intervene inorder to improve it, may be of recent originbut it is incontrovertible. Because of this, ithas already been recognized that "improve-ments in health conditions are desirable inthemselves, that they are an essential pre-requisite for economic growth, and that,therefore, they must be an integral elementin any meaningful development programfor the region" (Resolution A.2).

On signing the Charter of Punta del Este,the Governments of the Americas agreed towork toward the achievement of the healthgoals set forth in Title I, "Objectives of theAlliance for Progress," and in ResolutionA.2 containing the Ten-Year Public HealthProgram.

It is therefore fitting to examine thehealth problems of the Americas, as well asthe practical possibilities for gradually solv-ing them, in accordance with the spirit andthe letter of the Charter.

III. THE PRINCIPAL HEALTH PROBLEMSOF THE AMERICAS

For a given constitution and nutritionalstatus, the biological phenomena that con-dition health and disease hardly vary fromone person to another. Their social mani-festations, on the other hand, are for themost part the result of environmental fac-tors that vary in time and place. For some,health is the capacity of every human beingto adapt to his continually changing envi-ronment. In turn, the environment changesand improves with development, that is,with the application of modern technologyfor the promotion of well-being. Conse-

quently, any improvement in the environ-ment has a favorable effect on health.

The Americas are no exception to thisrule, so that the health problems in eachcountry reflect the trend of its development.

Thus an analysis of demographic indica-tors, such as morbidity and mortality rates,the population structure, the rate of growthof various sectors of the population, the dis-tribution of the population between therural and urban areas, and the main fea-tures of the labor force, makes it possible todeduce the nature of the prevailing health


problems. If these background data are re-lated to economic data-such as industrialand agricultural production, national in-come, average per-capita income, and en-vironmental conditions, especially sanita-tion, nutrition, and housing-these healthproblems can be even more accurately de-fined.

It is clear that degenerative and mentaldiseases and accidents are more frequent inthe countries that have a higher socioeco-nomic level, the industrialized and urban-ized areas of the Americas. In the re-mainder of the Hemisphere, that is, mostof Latin America, acute diseases, especiallythe communicable diseases, prevail. Healthprotection and health promotion techniques,together with the early treatment of pa-tients, can produce effects comparable tothose obtained in the technologically ad-vanced countries. The scientific knowledgeexists, but its application is hampered byeconomic and social factors.

In the world of today, economic and ma-terial values so outweigh cultural and spir-itual values that there is a tendency tocharacterize countries solely by their degreeof development. Those who do so overlookthe fact that development can be achievedonly if the way of life and dignity of theindividual citizen is respected and his col-laboration is enlisted. Social progress willnot endure if it is imposed in defiance of thecustoms and mores of the people.

We have interpreted the purposes of theCharter of Punta del Este as a cooperative

effort to stimulate the social progress ofLatin America concurrently with, and asthe outcome of, a sustained growth of theeconomy. As to health problems as such,we conceive of them as the aggregate offactors that condition the diseases and theirdistribution in each society. These are fac-tors of a biological, economic, historical, andcultural nature. Available data show thatLatin America is beset by infectious dis-eases, undernourishment, poor sanitation,unhealthful housing and working conditions,illiteracy, lack of proper clothing, and alow per-capita real income. These factorstogether produce a high general mortality,as well as a high mortality in children, es-pecially those under five years of age (morethan 40 per cent of all deaths), and acci-dents of pregnancy and motherhood whichlimit life expectancy at birth; they are alsoresponsible for the poor scholastic perform-ance of many schoolchildren, for low pro-ductivity, not to mention a pessimistic out-look on life. The distribution of these healthproblems among the countries varies, as itdoes among parts of the same country, andbetween the cities and rural areas.

It is a well-known fact that qualified pro-fessional and auxiliary personnel are in-sufficient in quantity and quality. The fundsavailable for the material resources requiredto promote and protect health are also in-sufficient. Priorities must be established toensure that investments in health give thebest possible returns and benefit as manypeople as possible.

IV. CRITERIA FOR ESTABLISHING PRIORITIESIN HEALTH PROBLEMS

An order of priority among health prob-lems clearly cannot be established unlessthe problems themselves, both their magni-tude and their social, cultural and economicrepercussions, are fully known. This back-ground information will make it possible to

decide which problems should be dealt withfirst, so that health, as a social function,may make the contribution needed for thebalanced development of the country.

Criteria for establishing priorities includethe nature and extent of the problems, their

Final Report 7

present or potential danger, measured interms of mortality and morbidity, and theirbearing on development. This approach em-phasizes the social impact of each problem.

Attention must likewise be given to thescientific knowledge available for prevent-ing or reducing the seriousness of each prob-lem. This knowledge can be applied throughtechniques that are reliable, relatively sim-ple to use, and inexpensive when comparedwith the financial consequences the problemhas for the community. This approach isclosely linked to the one mentioned earlier.

Another indicator for establishing priori-ties is public demand. When a problem is ofthe utmost importance, an actively inter-ested community eager to collaborate in itssolution is one of the most powerful factorsin applying the techniques recommended.This active and informed community par-ticipation becomes an educational processgenerating further cooperative efforts to-ward progress.

Finally, the agreements the Governmentshave entered into in connection with specifichealth problems are in themselves a cri-terion of priority. The Charter of Punta delEste is an outstanding example of such anagreement. Its objectives are continental inscope. It is up to the Governments to trans-late them into national terms by decidingwhich health problems are of the greatestimportance for economic development andsocial progress in their countries and howbest to solve them progressively. Malariaeradication is another good example.

The starting point for the establishmentof priorities is an accurate knowledge of theproblems. That calls for epidemiological in-

vestigation and reliable statistical data, afield to which urgent attention must begiven in Latin America. Vital and healthstatistics are still incomplete. Yet such dataare essential for formulating sound pro-grams, establishing targets, and evaluatingresults.

In applying the above-mentioned criteriafor establishing priorities, it should be bornein mind that specific programs related tospecific goals can more readily be seenand understood. Popular support can moreeasily be mobilized. Further, results aremore quickly obtained and progress takesa form that is more readily felt by publicopinion, which is stimulated to continuecooperating in other health programs.

Three types of approach to health prob-lems are suggested: First, to organize healthservices and provide them with facilities forthe protection of the physical environment,such as community water supplies, refuseand waste disposal, and food and pollutioncontrol. Second, to concentrate on specificdiseases, such as malaria and other para-sitoses, smallpox, diarrhea and enteritis,malnutrition and tuberculosis, among oth-ers. Third, to work on the health problemswhich are related to specific economic ob-jectives. If a country cannot reach the tar-gets set in its agricultural and industrialpolicy because poor health is draining theproductivity of its workers, then the healthproblems involved must have priority. Allof these approaches are visible and concrete.They provide a basis which allows politicalleaders and health workers to work togetherwithout sacrifice of principles.

V. THE PRESENT HEALTH SITUATION IN THE AMERICAS ANDTHE OUTLOOK FOR THE FUTURE

In the course of this century, and espe-cially in the last 20 years, substantial prog-ress has been made in the prevention andtreatment of diseases and in the promotion

of health in Latin America. As to the prev-alence of diseases in the countries, LatinAmerica may be considered a continent intransition, in which the great epidemic dis-


eases are in the process of disappearing.This is illustrated by the fact that in 1962only 3,082 cases of smallpox, 556 of epi-demic typhus, 527 of plague, and 48 ofjungle yellow fever were reported. Therewas no case of urban yellow fever. Not asingle case of cholera has been reported inthis century.

The incidence of other communicable dis-eases such as malaria, tuberculosis, leprosy,Chagas' disease, certain zoonoses, schisto-somiasis, typhoid and paratyphoid fevers,whooping cough, and diarrheal and entericdiseases remains high, despite the fact thattried and tested control methods are avail-able.

Nevertheless, chronic diseases are emerg-ing as a major cause of death in most of thecountries. In 1960 cancer, cardiovasculardiseases; and accidents were among the 10principal causes of-death, and in some coun-tries among the first five.l This is the re-flection of increased life expectancy, whichis closely related to the growing industriali-zation and accelerated urbanization of theHemisphere.

The above-mentioned social changes thatinfluence health problems, and are in turninfluenced by them, are occurring in a popu-lation of 206 million (1960) whose naturalgrowth rate is 2.5 per cent each year, thehighest in the world. It is a young popula-tion, 40 per cent of which is under 15 yearsof age; it has a birth rate of 40 per 1,000 anda mortality rate of about 12 per 1,000. Mor-tality is high in infants and in childrenunder five years of age. According to avail-able information, the former ranges from 50to 130 per 1,000 live births, whereas in tech-nologically advanced countries it is cur-rently only about 15. Mortality in childrenin the 1-4 age group is between 3 and 32per 1,000 population, whereas there areother-countries in the world where the index

'Summary of Four-Year Reports on HealthConditions in the Americas, 1957-1960. ScientificPublication PAHO 64, 1962.

is 0.8 per 1,000. As already stated, this agegroup accounts for more than 40 per centof the deaths that occur each year in Middleand South America. The fact that infectiousdiseases, malnutrition, and lack of sanita-tion, particularly of pure drinking water,are among the factors influencing mortalityin children aged under five, justifies thefundamental role of health activities in pre-venting this excessive loss of life, since itrepresents a loss of brains and hands neededto achieve social progress and economicgrowth.

There has been a gradual increase in lifeexpectancy at birth in the course of thecentury. The data available show that in1950 it was 33 years in one country, between40 and 50 in several others, and over 50 ina few. Few countries have been able to com-pute life tables based on the 1960 census,but these show a rapid increase in the last10 years with a life expectancy of about 60years or slightly more. In the economicallydeveloped countries the average life span isin excess of 70 years.

It should be pointed out that in 1960 theAmericas, which occupy one third of thetotal land surface of the globe, had a popu-lation of 405 million, or 13.5 per cent of theworld population. Of the total populationin Latin America, 52 per cent live in ruralareas. The average density in Latin Americais 10 persons per square kilometer.

According to the 1950 census, the eco-nomically active population in the Conti-nent was distributed as follows: agriculture,56 per cent; 'industry, 18 per cent; com-merce and services, 26 per cent. In NorthAmerica at the same date, not more than 15per cent of the total labor force was engagedin agriculture, yet these countries exportfoodstuffs. In Latin America, on the otherhand, according to the reports of the UnitedNations Food and Agriculture Organization(FAO), agricultural production declinedapproximately 2 per cent during the period1960-1961. Food production also dropped

Final Report 9

below that of the previous year, when therehad also been declines relative to the prioryear.' This differentiation between totalagricultural and food production is relevant,since there are large areas in Latin Americagiven over to the production of cash cropssuch as coffee, cocoa, sugar, tobacco, andcotton, not all of which are food.

Other important factors are deficient landuse and land tenure and inadequate storageand distribution of foodstuffs, because ofinsufficient use of modern food technology,which results in increased production costs.Both the quality and the quantity of foodconsumed are below par, and this gives riseto one of the fundamental problems in LatinAmerica: malnutrition.2

Per-capita income in Latin America isvery low, ranging from 100 to 1,000 dollarsa year. This figure must be viewed in termsof its power to purchase the necessities oflife: health, housing, clothing, drinking wa-ter and sanitation, working conditions, edu-cation, food, and recreation. Despite the ad-vances made, 40 per cent of the populationover 15 years of age is still illiterate, that is,about 50 million persons can neither readnor write. The average length of schoolingis three to four years.

. . .There are no statistics showing any ap-preciable improvement in rural income levels;indications are to the contrary, showing that, asa result of economic and demographic factors,most campesinos are now in a worse plight thanthey were a few years ago. The backwardnessof the agrarian sector continues to representthe principal obstacle to Latin American growthand is the major cause of social and politicaltensions and of many of the region's economicproblems.3

This quotation emphasizes the impor-tance that must be given to the rural prob-

' Inter-American Development Bank. SocialProgress Trust Fund. Second Annual Report, 1962,p. 122.

2 Oicial Document PAHO 48, 105-111.8 Inter-American Development Bank, op. cit.,

pp. 122-123.

lem in development programs, includinghealth programs. The fact is that, despiteindustrialization and efforts to diversifyproduction, the Latin American economyis predominantly agricultural. Generallyspeaking, each country is dependent on asingle export crop, the price of which, ac-cording to statements made by the Minis-ters of Finance, fluctuates sharply in theworld market. That has in large measurebeen the cause of the economic difficultiesof the countries, and has had an unfavorableeffect on the rate at which investments aremade and has inhibited development. It isthis fact which justifies the cooperative ef-fort envisioned in the Act of Bogotá and theCharter of Punta del Este, an effort es-sentially intended to improve living stand-ards in proportion as revenue increases andis redistributed among the priorities thathave a social effect.

The economic and social facts we havecited explain the nature of the health prob-lems prevailing in Latin America. They arepeculiar to a young population, which isgrowing at an accelerated rate, producesless than it needs, and supplies less than itdemands. The population structure, its agedistribution, and environmental and healthconditions are reflected in reduced workingcapacity, low productivity, and absenteeism.

Four tools are used to protect, promote,and restore health: planning; the organiza-tion and administration of services; theeducation and training of technical person-nel; and research.

Planning is the method recommended bythe Charter of Punta del Este for achievingits fundamental purpose: to promote a sus-tained growth of the economy and translateit into social well-being. To this end eachsector must formulate its own programs,covering the most important problems, thetechniques and procedures to be used tosolve them-depending on their urgencyand the experience acquired-the profes-


sional and auxiliary workers needed, equip-ment and supplies, and financing.

The formulation of a program calls forthe most accurate knowledge possible of theproblems, their magnitude, nature, and in-fluence on individual and collective health.Hence the importance of scientific and epi-demiological research, as well as of statis-tical information which, as pointed outearlier, is notoriously deficient in LatinAmerica. Nevertheless, it is possible todraw up health plans with the data avail-able at present and to establish specifictargets and objectives for each activity,within each population. At the same time,measures must be taken to ensure that thequality and the quantity of data are contin-uously improved. Statistical services musttherefore be organized, and professional andauxiliary personnel must be trained for spe-cific jobs in them.

Planning is only a means, not an end, andit is even more necessary for countries wherethere is a great disparity between needs andresources, a situation which necessitates thescheduling of problems and the channelingof investments to ensure that they will bene-fit the greatest number of people. Planning,in essence, is the mobilization of people,resources, and facilities to the best possibleeffect for the solution of problems. Planningthat is not specifically related to the prob-lem at hand is, at best, unrealistic and, atworst, sterile. Planning is not only knowingneeds; planning is doing. It is a continuousprocess that leads to the evaluation of whatis available against what is needed, and tothe mobilization of all the resources thatcan help.

At the present stage, sectoral health plansmust be prepared and related to economicgrowth. There is reason to believe that, asyet, a complete knowledge of the over-allplanning of development and welfare hasnot been attained. It is therefore essentialto try out various simple and suitable meth-ods in communities selected for that pur-

pose. Until this is done, it seems advisableto invest funds according to the prioritiesestablished in each sector, that is, health,education, agriculture, and so forth. Whendefinite criteria are lacking, there is littleto recommend attempts to increase invest-ments in one sector at the expense of thepriorities in others on the pretext of achiev-ing greater social and economic effects.Health, however, should always have a highpriority, because of its effect on produc-tivity and development.

Preventive and curative activities alreadyunder way should not be interrupted whileplans and programs, which are only a meansof achieving progress, are being prepared.This amounts to carrying out the immediateplans and the long-term measures referredto in the Charter of Punta del Este in sucha way as to fuse them into a continuousprocess.

The organization and administration ofhealth services, at both the local and thenational level, constitutes, together withtrained personnel, the most important toolfor carrying out activities for the preven-tion and treatment of diseases. Medicineand public health can attain their ends onlyif their techniques are adapted to the needsand resources of the peoples and to thespecial conditions created in each commu-nity by the local environment.

Organization and administration must.not be static or definitive. They must besubject to permanent review so as to facili-tate the attainment of the objectives of thehealth plan and its different programs. TheCharter of Punta del Este has emphasizedthe need for revising structures, legislation,institutions, rules, and regulations so as totranslate its general purpose into reality andimprove the standard of living.

Development in Latin America will pro-gress in proportion to the number and cali-ber of the expert and auxiliary personnelavailable for various activities. Health workis no exception to this rule, for one of its

Final Report 11

characteristics is that its functions are asdiversified as social life is complex. De-pending on the level of its development, acountry requires a series of professionals foreach health problem. The training of suchpersonnel is a rather lengthy process. It isgenerally agreed that large numbers of aux-iliary personnel must be trained so that aslarge a proportion of the population as pos-sible can be covered by the health services.Training must be programmed; in otherwords, the technicians needed for the vari-ous health activities must be prepared, postsfor them must be included in the budget,and they must be paid adequate salaries,commensurate with their dignity and loftymission.

As to research, the following quotation isrelevant:

The immediate purpose of supporting researchin Latin America is to solve problems related tohealth in a manner which will promote humanwelfare . . . The long-range goal is to promotethe upgrading of the community in its mosthuman aspects through the cultivation of science.Indeed, science, if understood properly as a formof culture, is a means of eventually providingthe whole community with an objective aware-ness of the proper context of man; it gives aholistic view of the universe, in keeping withman's intellectual nature; it will eventually pro-vide a basis for mutual understanding; and it isin any case a proper basis on which to buildeducation.1

The nature and distribution of diseasesand of the phenomena that condition healthhave special characteristics in the Ameri-cas, as they have in other regions of theworld. The social environment is varied andconstantly changing, as are the relationsbetween each environment and the humanbeings that live and develop in it. There istherefore, so to speak, a pathology peculiarto the Americas, which obliges the healthexperts to adapt and not simply to copyknowledge and techniques which have been

1Document TFH/3 (Eng.), 4 February 1963, p. 2.

worked out in other geographic areas. Thisfact justifies the need for investigating thephenomena that condition health and dis-ease in the countries and communities ofthe Hemisphere. To this must be added thepossibilities of contributing to the analysisof the origin of biological phenomena, aswell as ecological variations in differentenvironments resulting from attack proce-dures. Scientific research is not the antith-esis of pragmatism; on the contrary, theyare two facets of the same purpose.

An over-all view of the health conditionsin the Americas makes it possible to makecertain affirmations. There is a more precisedefinition of the prevailing problems andtheir influence on economic life and develop-ment. Nevertheless, the need for furtherknowledge of their magnitude and real ex-tent has become evident. It is possible toshow that there is a better understandingon the part of the urban communities.Furthermore, where social security systemshave been organized, the people have be-come conscious of a right. It is now fittingto stimulate the same attitude in the ruralareas.

The techniques and procedures used tosolve the problems are in accord with mod-ern principles. However, all the populationdoes not yet have access to them and attimes those who benefit are still very few.

In spite of the progress achieved in thetraining of health personnel, the numberand the quality of those available are notsufficient to satisfy present needs and thosearising out of the growth of the population.That is reflected in the distribution of healthservices, which shows an excessive concen-tration in urban centers and an absence orshortage in the rural areas.

In theory, activities for the protection,promotion, and restoration of health are ac-knowledged to be parts of the same process,which makes it advisable for them to coexistin the same organization. This is the thesisof the integration of health services to solve


the problems affecting the work unit-thefamily-and communities. Examples of thetranslation of this theory into practice inthe Hemisphere are few. Curative and pre-ventive services function as independentand uncoordinated authorities, and thisleads to a duplication of activities, waste,and poor utilization of the few resourcesavailable. If the law puts the responsibilityfor these activities on the ministries ofhealth, it is logical to concentrate in themall the activities that are now dispersedamong other public and private institu-tions that receive large financial contribu-tions from the State. Among these, themedical services of the social security sys-tem should be mentioned, as its role shouldbe limited to financing social benefits.

An administrative conscience and propercompetence must be developed to assure theefficient and economical use of limited re-sources. In this area many of the healthinstitutions in the Americas are very weakin terms of organization, regulations, proce-dures, and practices. Recognition must begiven to the fact that public administrationis essential to technology, and it must begiven the structure, the staff, and the equip-ment that modern methods demand. Ad-ministrative rationalization increases effi-ciency, decreases expenditure, and facili-tates the attainment of the objectives ofevery program.

Health investments in Latin America areless than what is needed for programs, as isshown by the vital and health statistics,despite the progress made in this century.According to a recent report of the Inter-American Development Bank,' 5.8 per centof the public expenditure of Latin Americais allotted to public health. This figurevaries markedly from country to countrysince in some of them it includes the costof social services. This fact will make itselfmore felt when the Governments formulate

'Inter-American Development Bank. SocialProgress Trust Fund. Second Report, 1962, p. 167.

their national health plans on the basis ofpriority of problems and programs for eachof their communities. Only in this way canthey determine the necessary funds thatmust be invested in health in each period.However, it is clear that domestic resourcesare not sufficient for prevalent problems,although it is recognized that with betterorganization and administration there is arelatively better return.

In view of their fundamental importancefor economic development, agricultural andindustrial development, and health, the Gov-ernments have obtained long-term creditsat low interest rates from internationalbanks with a view to financing water supplyand sewage disposal programs and housingprograms. It should be pointed out thaturban communities have shown themselvesready to pay higher water rates in view ofthe security that comes with proper watersystems. The Governments are investingmatching amounts of their domestic re-sources and at the same time have guaran-teed the amortization of the credits andtheir interest and the maintenance of theservice. In sum, properly organized publicutility enterprises are being set up. It isestimated that the same method is appli-cable to other health problems that can besolved through international credit. Thefirst annual meeting of the Inter-AmericanEconomic and Social Council, held in Mex-ico in October 1962, endorsed this opinion.The improvement of rural welfare, theeradication of malaria, the construction ofhospitals and health centers, the productionof vaccines, sera, and biological substancesfor human and animal use, and urbanizationprograms can be cited as examples. It wasrecommended that national and interna-tional credit institutions include varioushealth programs in their investment policy,in addition to water supply for urban, sub-urban, and rural areas, with a flexiblefinancing system to cover the various itemsin these programs.

Final Report 13

There has never been a sustained effortin Latin America to organize voluntarycollaboration for health objectives either atthe community or at the institutional level.It is urgent to do so because there is a latentmotivation and a desire of many people tocontribute their efforts and even their goodsfor higher purposes.

International organizations, both govern-mental and private, bilateral and multi-lateral, have given technical advice andeffective and humanitarian assistance toLatin America. This has made itself feltin the formulation of programs, the organi-zation of services, the construction andequipping of hospitals and health centers,and especially in the education and trainingof technicians.

In the Alliance for Progress, we special-ists in health feel that we are a part of "avast effort to bring a better life to all thepeoples of the Continent." We must devoteour best abilities to making that goal areality. We recognize that what is essentialfor this purpose lies in our countries, inthe present and potential ability of theinhabitants, as well as in the natural re-sources. Nevertheless, it is indispensable tocarry out the legal and institutional reformscalled for by the Charter of Punta del Estein order to obtain the greatest benefits forthe country from the national resources.External capital is needed in order to cata-lyze the process of development and com-plement the national efforts. And it is like-

wise needed for economic and social welfareprograms. The last mentioned are stimu-lated by the aspirations of the human beingsin whom the Alliance for Progress hasawakened justified hope. The Task Forceon Health would like the administrativemachinery of the Alliance to show greateragility and flexibility for carrying out pro-grams for social progress and economic de-velopment.

To accomplish the objectives of the Alli-ance for Progress and to carry out the Ten-Year Public Health Program, Latin Americahas a solid basis whose most valuable fac-tor is the spirit of its people, its universitiesand teaching and research centers, and itsprofessional and auxiliary workers. It isnecessary, however, to accelerate the processof training; to formulate plans and pro-grams; to rationalize public administrationand make services more efficient; to increaseinvestments, of both domestic resources andexternal assistance, as the economy growsstronger; to intensify the active and in-formed participation of the people for thecommon good, which is public health. Thesegeneral measures are essential for the sup-port of the specific measures related to eachparticular problem.

In sum, the Alliance for Progress repre-sents an additional contribution to the ef-forts and programs in the field of healthwhich each country is promoting to solveits own problems.

VI. MEASURES RECOMMENDED FOR THE IMPLEMENTATION OF THE TEN-YEARPUBLIC HEALTH PROGRAM OF THE ALLIANCE FOR PROGRESS

The Ten-Year Public Health Programof the Alliance for Progress set forth inResolution A.2 of the Charter of Punta delEste contains both long-term measures andthose to take immediate effect for the pur-poses of reaching its objectives.

The former relate to the means habituallyused to secure the protection, promotion,

and recovery of health: planning, organiza-tion and administration of services; educa-tion and training; and research. The latterrefer to specific problems that are prevalentin Latin America.

The committees established by the TaskForce gave priority to an analysis in depthof those measures. They discussed the back-


ground of each problem, which was avail-able to them in the working documentsprepared by the Advisory Groups of thePan American Sanitary Bureau and by itstechnical staff. This information made itpossible to distinguish the aspects of eachproblem which at present constitute thegreatest obstacles to a solution. The com-mittees centered their attention on thoseaspects and proposed practical measuresthat experience has shown to be advisablefor Latin America.

This chapter of the Final Report containsa summary of each problem, together witha justification of the recommendations ap-proved by the Task Force.

A. Specific Measures

A.1 Malaria Eradication

While notable progress has been made inthe malaria eradication campaign, muchremains to be done in order to free theHemisphere of this disease.

By the end of 1962, of the estimatedpopulation of 153.7 million in originallymalarious areas of the Hemisphere, 59.3million were living in areas in which thedisease had been eradicated; 30.4 millionwere in zones already free of transmissionand now in the consolidation phase; 49.3million were in areas that are in the attackphase; and 14.7 million in areas where thestart of the campaign is still awaited. It canbe said that 58.4 per cent of this populationin the Hemisphere is now living in areas freeof transmission.

The attack phase is still to be started inCuba and is paralyzed at present in Argen-tina and Paraguay. In several countries thecampaign is not advancing because of alack of funds to intensify the attack meas-ures. Before analyzing this special situation,some other no less important factors areworth considering.

Inasmuch as the goal sought is the eradi-

cation of malaria, the problem is concen-trated for the moment on the 64 millionremaining inhabitants who are still subjectto the disease. Of these inhabitants, thePan American Sanitary Bureau estimatesthat close to 6 million are living in so-called"problem areas," that is, areas in which ithas been established that the application ofDDT or dieldrin is not by itself enough toeradicate malaria.

To achieve the objective in such areas,it will be necessary to employ larger finan-cial resources in order to apply supplemen-tary control methods such as peridomicili-ary fogging, mass medication, and anti-larval campaigns, according to conditionsin the individual area. Where the populationis concentrated and the breeding grounds ofthe anopheline mosquitoes are limited, anti-larval efforts can be successful at a rela-tively low cost. Where the population isscattered or where there are many and ex-tensive breeding grounds, mass medicationof the inhabitants will be more efficient.

At the present time, to produce satisfac-tory results in mass medication the anti-malaria drugs must be administered orallyat short intervals. If the rate of transmissionis high, this interval should be of not morethan two weeks, which will require a largenumber of distributors of the drugs. Thiscost can be reduced in the future if newdrugs having prolonged residual action arediscovered.

For the problem areas in which there isno extradomiciliary transmission and thevector is resistant to DDT and dieldrin,new insecticides can be applied. Organo-phosphorus and carbamate compounds arealready available commercially. However,these insecticides are expensive and mustbe applied at least three times a year.

When the habits of the vector so require,it is advisable to spray houses to a levelabove 10 feet, including ceilings, and otherrelated structures.

The priority needed for the campaign is

Final Report 15

not limited to the financial sector. In orderto have a chance of success, the campaignmust be well planned, adequately financed,well administered, and directed by compe-tent professional personnel. Failure to meetany of these four conditions may endangerthe possibility of attaining the goal agreedupon.

It is also essential for the administrationof the campaign to be protected againstinterference from outside interests. The ap-pointment of incompetent personnel will befatally reflected in the discipline prevailingat all levels. The campaigns that have beenmost successful so far are those in whichthe director has authority to select andmanage personnel in accordance with spe-cially prepared regulations in which theminimum qualifications required for eachduty are clearly established.

It has likewise been observed that whenthe directors of the campaign share theadministration with a national council underthe chairmanship of the minister of healthand including representatives of the na-tional and international authorities directlyinterested in the matter, the problems thatarise are solved more quickly and suitably.The council helps the director perform hisduties, always maintains a high standardof efficiency and conduct, should have au-thority to approve the annual budget, andis responsible, jointly with the director, forthe coordination of the campaign with theother governmental departments and theexisting medical care institutions. To attainthese objectives, the council should meet atregular intervals.

An attack to interrupt transmission of adisease must be continuous and progres-sively increasing. Every malaria eradicationcampaign must be accompanied by epide-miological investigations that will make itpossible to assess the variations or changesthat are occurring in the ecology of thedisease as advances are made in the plansof attack. One important condition that

should be carefully investigated after thefirst spraying of the houses with any resid-ual-action insecticide is the speed withwhich the transmission of malaria is re-duced. Once the reasons for delay in suchreduction are known, proper supplementarymeasures must be applied. These measures,however, must not be at the expense of theevaluation operations, which are as impor-tant as those of attack.

Unfortunately, it has been observed thatthe epidemiological studies made in the ma-laria eradication campaigns now under wayhave not always been adequate, because ofthe lack of a sufficient number of competentpersonnel. It is therefore considered advis-able that additional efforts be made to in-crease the number of epidemiologists andother auxiliary technicians, taking care toimprove the quality of their biological andscientific training.

The evaluation operations will be lesscostly in proportion as cooperation is in-creased between existing public and privatemedical care services in case-finding activi-ties, reinforced by a network of volunteerworkers. Unfortunately, medical care forthe rural population in Latin America israther poor, especially in malarious areas,which makes it necessary for the campaignsto support a large number of employees todetect cases.

As one of the principal objectives of theCharter of Punta del Este is "to encourage. . programs of comprehensive agrarianreform . . . so that the land will becomefor the man who works it the basis of hiseconomic stability, the foundation of his in-creasing welfare, and the guarantee of hisfreedom and dignity," it is to be hoped thatGovernments will give priority to the ex-tension of their health services to the ruralareas which, at such great financial expense,have been or will be liberated from malaria.

This assistance can be begun by utilizingthe same auxiliary malaria evaluation per-


sonnel to provide other simple but essentialhealth benefits to the rural population.

The immediate, crucial problem in ourHemisphere is still the financing of localcosts. As yet the credit institutions havemaintained a certain reserve, even thosethat have been created to assist in theeconomic development of the most impover-ished nations.

For their part, the Governments considerthat if they are to maintain a balance be-tween all the responsibilities incumbent onthem, they cannot possibly increase theallocations for the malaria eradication cam-paigns above their current level.

One solution would consist in mutualassistance; the Governments of the coun-tries that have had the most success ineradicating malaria from their territories-or have reached a very advanced stage insuch eradication-might given economicand technical assistance to their less favoredneighbors.

Inasmuch as malaria eradication is ahemisphere-wide program, its objective canbe considered reached only when no moreindigenous cases of the disease occur in theentire Region of the Americas, includingNorth, Middle, and South America. Thepresence of autochthonous malaria in anycountry constitutes a threat to all the coun-tries that have achieved eradication of thedisease from their territory. Under the cir-cumstances, it is of interest to the Hemi-sphere for each Government to assign thehighest priority to this program, not onlyfor its own benefit but for the benefit ofthe other countries as well.

Because of the fact that in a large partof the malarious areas this disease is a pre-dominant factor in general mortality, andespecially in the deaths of children underfive years of age, it is clear that in thoseareas the first priority for attaining theobjectives of the Ten-Year Public HealthProgram adopted along with the Charter

of Punta del Este belongs to malaria eradi-cation.

Border coordination should be increasedin some countries, and if participation ofthe Pan American Sanitary Bureau is con-sidered desirable for this purpose, it shouldbe requested. Such coordination seems moreessential for certain groups of countries, asin the case of the Central American coun-tries.

The budgetary allocations available insome countries at present are not sufficientto cover the expenditures needed for themalaria eradication campaign, but sincethe disappearance of malaria brings withit economic improvement of the area, it isfelt that a country may request foreign aidwhen it needs it, in the form of loans tohelp it meet its needs in this field. For thisreason it is suggested that approaches bemade to the credit agencies to urge them togrant loans of this sort.

A.2 Tuberculosis Control

The lack of complete and reliable infor-mation in most of the countries makes itimpossible to determine satisfactorily theprevalence and incidence of tuberculosis inthe Americas.

Document TFH/11 includes tuberculosismorbidity and mortality statistics obtainedfrom the Governments of the Hemispherefor the period 1955-1960. Deaths from thiscause in 17 Latin American countries were35,000 in 1958. Taking as a basis the datafrom the countries that have registrationsystems, it can be estimated that the num-ber of deaths from tuberculosis in a yearwas at least 54,000. The death rate de-clined in only 7 of these countries duringthe period; it remained the same in 8, andincreased in 2. The number of cases noti-fied in 1958 was 100,500. It can be estimatedthat there were at least 270,000 new casesper year. The number of cases notified eachyear increased in 9 countries, remainedbroadly the same in 6 and decreased in 3.

Final Report 17

When there is a good case-finding pro-gram, it is possible to trace up to 11 casesfor each death during a year, which wouldproduce an estimate of some 600,000 activecases.

Even within the limitation of the avail-able statistical information, it can be said,as the Charter of Punta del Este indicates,that tuberculosis continues to be an impor-tant problem in Latin America, because ofthe harm it causes to the population andbecause of the lack of services necessary forapplying the already proven techniques toall persons suffering from the disease.

Thanks to the rapid advance in scientificknowledge in recent years, specific meanshave now become available for combatingtuberculosis. Notwithstanding their intrin-sic limitations, they are sufficiently effectiveto make a substantial contribution to thesolution of the problem. The difficulty ariseswhen these procedures have to be put intopractice.

At present tuberculosis can be regardedas an infectious disease that can be broughtunder control by using the specific meansavailable and by methods that, generallyspeaking, are applicable to the control ofhighly prevalent, protracted diseases. Ex-isting and potential sources of infectionmust be found, the tuberculosis cases mustbe found and rendered noninfectious, thefollow-up of patients must be organized,and secondary chemoprophylaxis and BCGvaccination must be administered.

In practice, this means a program of case-finding and treatment and of vaccinationand chemoprophylaxis. Case-finding mustbe based on the simplest diagnostic methodsnow available: miniature X-ray examina-tions, sputum examinations, and tuberculintests. For treatment to be economicallyfeasible it must be based on ambulatory ordomiciliary chemotherapy for the majorityof cases.

It should be borne in mind at all timesthat the aim of tuberculosis control is to

reduce the spread of the disease in thecommunity and ultimately in the wholepopulation, and insistence should thereforebe laid on the use of standardized objectivesand the cheapest possible diagnostic andtreatment methods, although some of themare undoubtedly not so satisfactory as thebest and most elaborate that are now avail-able. Should other more effective meansnot be available, sputum examinations arerecommended for the discovery and treat-ment of cases.

Antituberculosis activities should be pro-grammed in a continuing and long-termmanner, and consequently should have thebenefit of permanent services. Moreover,since tuberculosis is one of many problemsthat affect a community and since many ofthe activities undertaken to combat it arethe same as or similar to other health ac-tivities, the antituberculosis services (what-ever their level of development) should .beintegrated within the existing public healthagencies and services, including those formedical care.

While it is not possible to establish gen-eral guidelines or outlines for the progres-sive application of this concept, it is empha-sized that it should be applied in eachcountry as an effective way of carryingout continuing and long-term work, throughpermanent services established in the com-munity.

In summary, the aim pursued is to attacktuberculosis effectively and economically bythe most rational application of availableknowledge and resources, in accordance withthe local technical, social, and economicconditions, within a broad public healthprogram. The objective is to eliminate tu-berculosis as a public health problem asrapidly as is compatible with the over-allpublic health needs in each country.

A.3 Smallpox Eradication

Despite the excellent results obtained bythe various countries which have achieved


eradication or are in the process of gradu-ally reducing the incidence of smallpox, thedisease continues to be a serious publichealth problem in the Hemisphere, as isshown by the fact that it is present inseveral countries and a considerable numberof cases occur each year.

Between 1947 and 1962 the countries andterritories of the Americas reported 168,957cases of smallpox, as shown in Table 1 ofthe working document.1

As national smallpox vaccination cam-paigns were carried out, the disease disap-peared or was rapidly reduced in areaswhere it was formerly prevalent; it now re-mains only in the countries that have notyet begun their eradication programs or inwhich such programs have been either in-terrupted or not carried out rigorouslyenough.

Table 1 of the above-mentioned docu-ment shows the situation in 1962. At thepresent time Brazil and Ecuador are thetwo most important foci in the Americas.Since in many of those areas the number ofvaccinations given is low, most of the popu-lation is susceptible to the disease.

The resounding success achieved by mostof the countries of the Americas in eradicat-ing smallpox is endangered as long as foci ofthis disease persist in the Hemisphere. Fortheir own protection, those countries whichhave no smallpox must continue to maintaina high level of immunity by means of regu-lar smallpox vaccination programs coveringannually at least one fifth of their popula-tion. The high costs of this measure can bereduced only when smallpox eradication hasbecome hemisphere-wide.

The eradication of smallpox from theAmericas requires the joint efforts of all in-terested countries, both for the protection oftheir population and for the protection ofthose countries that have already adoptedthe necessary measures to eradicate thedisease.

1Document TFH/11 (Eng.), 8 March 1963, p. 23.

In numerous resolutions, the GoverningBodies of both the World Health Organiza-tion and the Pan American Health Organi-zation have voiced their interest in andconcern over the smallpox problem in theAmericas, and have recommended that thecountries that have not yet eliminated thedisease should accelerate or initiate eradica-tion programs, as the case requires.

The delays in carrying out these recom-mendations are due to both financial andadministrative difficulties. It is to be hopedthat the Governments will make everyeffort to overcome these difficulties and togive the smallpox eradication program theimportance and priority it deserves fromthe point of view of national and inter-national health.

An effective vaccine against smallpox hasbeen available for more than a century anda half, and if it is applied systematicallyand in an organized manner, it will providecomplete protection of the population.There is no doubt that the eradication ofsmallpox from the Americas can and shouldbe achieved. Today there is a sufficientamount of good quality vaccine availablefor the purpose. Furthermore, all the coun-tries have sufficient technical resources intheir health services to complete the small-pox eradication program and to maintainfreedom from the disease.

A.4 Chagas' Disease

Recent investigations on Chagas' disease 2have shown its great clinical and epidemio-logical importance, which justifies its in-clusion in the health plans of the countrieswhere it is prevalent. The disease may affectthe fetus, and especially afflicts infantsunder five years. It also causes impor-tant cardiac and gastroenteric pathologicalchanges in adults.

2 Document TFH/3 (Eng.). Report of the FirstMeeting of the PAHO Advisory Committee onMedical Research, pp. 83-98.

Final Report 19

The problem arises from the poor qualityof rural housing in areas where Chagas'disease is endemic, and from the popula-tion's ignorance of the part played by thevector in transmitting the disease. On theother hand, only exceptionally have thenational plans for new construction or reno-vation of housing been extended to ruralareas in Latin America. Undoubtedly, therenovation of dwellings brings about a radi-cal change in the ecology of the vectors andreduces their density.

Nonetheless, stress should be laid on theurgency of expanding and intensifying theuse of insecticides, because of the immediateresults that can be obtained in applyingthem.

It also appears highly advisable forhealth education programs to be carried outon an urgent basis with a view to enlistingthe population's cooperation in the cam-paign against the triatomes.

A.5 Nutrition

Today in Latin America it is estimatedthat more than one half of the populationis suffering from malnutrition to a greateror lesser degree. Malnutrition exists inmany forms; however, our principal inter-ests are protein-caloric malnutrition, en-demic goiter, anemias, and certain specificvitamin deficiencies.

This situation is in part due to insuffi-cient or misdirected agricultural production,a failure to apply modern methods of tech-nology to food storage and distribution, lowpurchasing power of the individual, wide-spread ignorance of good dietary practices,and the presence of certain other endemicand enzootic diseases.

With regard to food supply, productionin Latin America has risen steadily duringthe last two decades, by a total of 69 percent. However, population increases havebeen so rapid that per-capita food produc-tion is now 1 per cent below pre-World

War II levels, which in themselves wereconsidered unsatisfactory.

Population growth continues rapidly andit has been estimated that the world's popu-lation will double itself by the year 2000.Considerable increases in agricultural pro-duction will have to be achieved, therefore,even to maintain the status quo. Actually toimprove the existing and future nutrition ofthe population will require even greaterefforts.

Food production per se, however, will notimprove the nutritional status of the popu-lation. The type of food produced is of con-siderable importance, as is its destination interms of individual use and national eco-nomic planning. Food production should beoriented to supply all or most of the needsin terms of quality and quantity, and eco-nomic policy should be aimed at satisfyingnational food needs rather than exportingessential food items.

One of the principal nutritional deficien-cies in Latin America is that of protein. To-day, many new sources of this nutrient have*been developed, such as fish, cottonseed,peanut, and soy bean flour, which can to agreat extent replace traditional animal pro-teins. To date, however, there has been littlemass production and development of thesesources, and consequently they have 'notcontributed significantly to the eliminationof severe protein malnutrition.

In terms of development of sources ofanimal proteins, foot-and-mouth diseaseand hydatidosis diminish considerably theproductivity of cattle herds. It is estimatedthat, with the control of these diseasesalone, livestock production would be in-creased by more than 25 per cent.

Every year considerable losses of cropsand stored foods due to rodent and insectdamage further diminish the supply ofavailable foodstuffs.

In the field of health, malnutrition con-tributes greatly to existing problems, es-pecially in the so-called nutritionally vul-


nerable groups of pregnant and lactatingmothers and preschool children. The age-specific death rate in the 1-4 year group isa good indicator of nutritional status in thepopulation. Today in Latin America thereare many areas where the mortality rate inthis group is 30 times higher than in well-nourished populations, while specific deathrates from such diseases as measles anddiarrheal disease are 100 to 200 timesgreater. In terms of health services, the highcost of hospitalization of severely malnour-ished children represents a considerableburden on the local health service's budget.Malnutrition has been shown to cause con-siderable retardation in the physical andmental development of the child. This situa-tion results in poor physique and low in-telligence levels in the adult, which in turnhave serious repercussions on the economicdevelopment of a country.

Widespread specific deficiencies of iodineand iron cause high morbidity rates fromendemic goiter and anemia. Certain specificvitamin deficiencies also contribute to lowerresistance of the individual to common in-fectious diseases. By means of such simpleprocedures as iodization of salt and cerealenrichment, much can be done to rectify thesituation. However, few countries in theHemisphere have so far adopted suchmeasures.

Food distribution programs are now wide-spread and serve to alleviate the existingfood shortages. However, these cannot beregarded as a permanent or complete solu-tion to the problem. Education in all aspectsof food and nutrition science is the onlyeffective and lasting means of combatingwidespread malnutrition. At present thereis a great lack of intermediate-level special-ists in nutrition to carry out such work. Ithas been estimated that approximately2,000 nutritionists will have to be trainedduring the next five years in order to satisfycurrent needs.

A.6 Environmental Sanitation

The Charter of Punta del Este providesthat potable water and sewage disposalshall be supplied for at least 70 per cent ofthe urban and 50 per cent of the rural popu-lation during the present decade. Recentstudies indicate that 41 million inhabitantsin urban areas lack water in their homes,and that this deficiency is even greater withregard to sewerage. Figures with regard torural areas are very incomplete. It has beenestimated, however, that about 70 per centof the population which lives in communi-ties of from 2,000 to 10,000 inhabitantslacks potable water. These data, along withthe natural increase of the population, re-veal that in the decade 1961-1971 it will benecessary to install water and sewerageservices for at least 44 million inhabitantsin the urban areas and 58 million in therural areas.

Besides the inherent economic losses, it isurgent to improve this situation because ofthe importance of water for industrial andagricultural development. This is even moreimportant if one considers the high rate ofmortality of infants and of children underfive years of age, as well as the morbidityfrom enteric infections, which are due to thecontamination of water, of the soil, and ofproducts in general. While it is estimatedthat water services have been installed forover 25 million inhabitants in the pastdecade, the rate of construction of newservices and of expansion of existing oneshas been very low in relation to the demo-graphic increase.

There are very marked differences in theextent and effectiveness of the water andsewerage services in the various LatinAmerican countries. In general, they havebeen established in the central areas of themost important cities, and the highest in-come groups are the principal ones thatbenefit from them. Furthermore, the serv-ices are deteriorating rapidly, since the

Final Report 21

equipment has been used beyond its normalcapacity.

In the opinion of the Advisory Committeeon Environmental Sanitation of the PanAmerican Sanitary Bureau,l the goal estab-lished for the supply of water in urban areasin the Charter of Punta del Este is a realis-tic one and can be attained or surpassed inmost of the countries.

The effort of Governments and of the in-habitants during the past two years isworthy of high praise, as is the interestof international credit organizations, espe-cially the Inter-American DevelopmentBank, in financing water services. Recentreports from the Bank show that since thebeginning of its operations it has approvedloans for 157 million dollars, which alongwith a similar amount from domestic re-sources will benefit about 15 million personsin 12 Latin American countries. In additionto good organization and business adminis-tration, due importance must be given towater rates in order to assure the mainte-nance and expansion of services, as well asthe amortization of capital and interest.Experience shows that the urban communi-ties of the Americas are ready and willingto contribute reasonable amounts in orderto obtain an element which is vital for them.

These developments are a part of thepolicy established by the Governments ofthe Americas in the World Health Organi-zation and the Pan American Health Or-ganization, and they represent the standardwhich must be applied during this decade inorder to carry out the objectives of theCharter.

With regard to rural areas, the above-mentioned Advisory Committee of the PanAmerican Sanitary Bureau considers that itis possible to make potable water accessibleto 50 per cent of the rural population. If thepopulation is concentrated in villages orhamlets, measures should be taken to make

'Document TFH/2 (Eng.), 5 February 1963,p. 10.

water available in homes. The cooperationand participation of the community is basicand, if well motivated, the community maylend its own efforts or even funds for carry-ing out projects. Basic capital, a true fundfor rural well-being, is needed, however, if itis desired to carry out the above-mentionedobjective of the Charter. This fund may befinanced by the Governments of the Hemi-sphere, including contributions from the Al-liance for Progress. Governments might ob-tain credits, which they would, in turn, lendto organized communities for the purpose ofcarrying out sanitation works in the firstplace, and then other projects aimed at im-proving living conditions in the rural areas.Through a reasonable installment system itmight be possible to recover a high propor-tion of the capital outlay, which could thenbe loaned to other communities as if it werea revolving fund. The Pan American Sani-tary Bureau might be entrusted with thestudy of this proposal and the means forcarrying it out, following consultation withthe interested Governments.

In view of the magnitude of the problemsof urban sanitation and the responsibilitieswhich have been acquired by institutionsorganized for this purpose, it is felt that theministries of health must have the responsi-bility for the planning, construction, andmaintenance of projects in the rural areaswhen the necessary financing is forthcom-ing. On the other hand, they must maintainthe right to supervise the sanitary condi-tions of all the water and sewerage systems,as well as to approve plans for new installa-tions before construction is begun. To thisend Governments should strengthen theirenvironmental sanitation departments, notonly by adding the necessary personnel, butby strengthening the position of the depart-ment within the ministry, its budget, and itsresponsibilities.

Recent possibilities of speeding up thesupply of water in the Hemisphere havegiven particular urgency to the training of


sanitary engineers and auxiliary personnel.Their present number is less than the re-quirements for the programs which havebeen financed. Particular attention must begiven to this problem if it is desired tofulfill the sanitation objectives in the Char-ter of Punta del Este. In civil engineeringcourses thle teaching of basic notions of sani-tary engineering should also be strength-ened, as it should in courses for other pro-fessionals, such as those concerned withhousing construction.

It is estimated that more than half of thepopulation of Latin America is living in in-sanitary housing. The ministries of healthmust take a more active part in the sanita-tion aspects of housing projects. For thispurpose a closer coordination between theresponsible State organizations is needed.The rapid industrialization of many areas iscreating problems of occupational health, aswell as of air and water pollution. Wherethese problems are given priority in thehealth plans, it will be essential to deal withthem in accordance with existing knowledge.

One measure that can help solve theproblems created by industrialization is de-centralization. In fact, it is believed that ifindustries were to be transferred to ruralareas, not only would the amount of invest-ments needed for water supply and seweragesystems be reduced, but new incentives fordeveloping the rural areas would be created.

B. General Measures

B.1 National Planning for Health

The Charter of Punta del Este recognizesthat in order to achieve the objectives of theAlliance for Progress it is necessary to pre-pare national programs of economic andsocial development. These plans should in-corporate the countries' efforts toward theimprovement of human resources and thewidening of opportunities by raising thegeneral levels of health and education,

and by improving and expanding technicaltraining and professional education.

The Ten-Year Public Health Programcontained in Resolution A.2 of the Charterrecommends the preparation of nationalplans among the long-term measures for theprevention of disease and the promotion andrestoration of health.

This will require taking a series of steps,forming a continuous process that beginswith the formulation of a general healthpolicy within the framework of a nationaldevelopment plan. This general formulationshould be followed by a study of the prob-lems and their quantification, an analysisof the physical and human resources avail-able, assignment of priorities, establishmentof goals, selection of the most suitable tech-niques, and development of methods of re-porting and evaluation for the purpose ofperiodically readjusting the objectives toconform to experience.

Statistics for most Latin American coun-tries are incomplete, so that existing planshave been but a statement of general policywith regard to specific problems. As prob-lems become better known, it will be possi-ble to formulate precise goals referring spe-cifically to regional or local needs. Nationalplans will, in the end, be expressions ofintent with regard to health in a specificperiod. In this way it will be possible todefine the objectives of the plan more pre-cisely. For this reason, it is said that anational health plan is a means, an instru-ment, part of a continuous process, in whichthe original proposals are improved as ex-perience accumulates and performance isevaluated.

There is therefore ample justification forestablishing planning and evaluation unitsat the level of the ministries of health, asrecommended in Resolution A.2 of the

Charter of Punta del Este. These unitsshould be staffed with experts especiallytrained in planning. It is also essential forthe health ministries to be represented on

Final Report 23

national boards or agencies responsible forplanning economic and social development,in order to ensure coordination.

The methodology of preparing plans andprograms should be known to the largestpossible number of health experts. Trainingin this field is an especially urgent need. Itis therefore recommended that such trainingbe intensified. The courses begun by theLatin American Institute for Economic andSocial Planning in cooperation with PASB,and at certain universities of the Americas,are very useful. Experts so trained shouldorganize planning units within the minis-tries, and guide those responsible for re-gional and local health agencies in thetechniques of planning.

Without a suitable statistical basis it willbe difficult to improve the process of plan-ning. This is the reason for the recommen-dation to the Governments "to improve thecollection and study of vital and healthstatistics as a basis for the formulation andevaluation of national health programs"(Resolution A.2 of the Charter).

In spite of training programs in statisticsand the progress made in some countries,there still exist serious deficiencies in thequality and quantity of data. For this rea-son, knowledge of health problems is in-complete. Only 12 Latin American countriestook censuses between 1960 and 1962; inseven countries they are scheduled in 1963;one country has not as yet reported. Theabsence of data from recent censuses makesthe analysis of health problems extremelydifficult and affects plans and programs.Systems of birth and death registration areoften inadequate in both quality and cover-age. The same applies to statistics on healthservices and basic data for programming atall levels of health organization. Moreover,statistical services are not always located ata suitable administrative level in the min-istries of health.

One of the objectives of the Charter is toincrease life expectancy at birth by at least

five years during the decade. To measureprogress toward this end, it is essential toconstruct life tables; only those countrieswhich have had a recent census and keepsuitable death records will be able to do so.It is recommended that "registration areas"be established in each country, in which itwill be possible to compile and analyze vitaland health statistics. These data will permitmore precise formulation of national plansand the determination of life expectancy.Such demonstration areas may be progres-sively extended throughout the country asstatistical experts are trained and localhealth organization improves.

It has been pointed out that, according tothe spirit and the letter of the Charter ofPunta del Este, health is an essential com-ponent of national development, and thathealth programs should be incorporated intoeconomic and social plans for each country.It is therefore necessary to achieve closecoordination between experts in the varioussectors, in order to assign resources so as toattain the greatest social progress. Themethodology of planning, however, stillneeds a great deal of research and analysis,especially for establishing priorities for eachlocality and region, which will make itpossible to distribute resources within eachsocial sector.

The collaboration of international agen-cies has proved useful in this field, both inthe training of experts and in advisory serv-ices to Governments for the preparation ofplans. It is recommended that coordinationamong the several international agencies beimproved. It is also suggested that jointmissions requested by Governments shouldinclude health experts.

Resolution A.2 of the Charter of Puntadel Este recommends:

To adopt legal and institutional measures toensure compliance with the principles and stand-ards of individual and collective medicine for theexecution of projects of industrialization, urbani-


zation, housing, rural development, education,tourism, and others.

This proposal points to the responsibilityof ministries of health in all projects under-taken by countries to promote economicgrowth and social welfare. Health programshave not always been included in projectsmentioned in this recommendation.

Good organization and administration ofservices is basic to every health programand, therefore, to the fulfillment of the ob-jectives of the Alliance for Progress. It isessential to create an administrative con-science, a true motivation for obtainingbetter results at lesser cost. Public adminis-tration is therefore a basic function at theservice of the technical field. Regrettably, inthe health ministries in the Americas pub-lic administration is often inadequate tomeet the complex operations of the variousinstitutions. This explains why the person-nel and the knowledge available are notalways effectively used.

It is therefore necessary to improve theadministrative systems being used by ap-plying known scientific principles. Specialattention should be given to structure, fi-nance and budget, personnel, purchasing,and operation and maintenance of buildingsand installations.

It will further be necessary to train ad-ministrative personnel. Senior administra-tors require university preparation; othercategories can be given in-service training.Health administrators must apply the prin-ciples of administration and be able todelegate responsibility, along with the au-thority to exercise it.

B.2 Improvement of Health Services

The American Republics, in adopting theprogram of action to establish and carryforward the Alliance for Progress, agreedon certain goals for the present decade,among them "to improve basic health serv-ices at national and local levels" (Title I,par. 8, Charter of Punta del Este).

In the Ten-Year Public Health Programof the Alliance, it was recommended thatthe Governments, among other measures:

Improve the organization and administrationof national and local health services by combin-ing the functions of prevention and cure; obtaina better return from medical care services;create the necessary services gradually; and en-sure financial accessibility to therapeutic agentsand means for the prevention of disease (Resolu-tion A.2, par. 1-e).

Among the measures to take immediateeffect, the same resolution recommendedthat the Governments:

Take measures for giving increasingly bettermedical care to a larger number of patients, byimproving the organization and administrationof hospitals and other centers for the care andprotection of health (par. 2-b.5).

These goals reflect the importance at-tributed *by the signers of the Charter ofPunta del Este to the need for viewing theprevention of disease and restoration ofhealth as a continuous process, harmoni-ously planned, and carried out on a co-ordinated basis, to produce the greatestresults in terms of efficiency and scope ofaction.

The documents compiled by the PASBSecretariat include th'e Final Report of theAdvisory Group on Medical Care, convenedby the Director of the Bureau in March1962, and the working documents and re-port of the Technical Discussions at theXVI Pan American Sanitary Conference,held in Minneapolis, Minnesota, in August-September of the same year.1 These docu-ments reflect the same purpose, reinforcingand reiterating the aspirations of those whoconceived the Alliance for Progress andestablished its goals and guidelines foraction.

The doctrine of integration admits of noseparation between prevention and cure.Among the social functions of medicine, itpoints to those that are carried out in the

'Document TFH/9 (Eng.), 8 March 1963.

Final Report 25

community, including the services broughtto bear to protect, promote, and restorehealth. This concept implies that there isa mutual dependence between individualand collective medicine. Both tend to sus-tain the individual in the best state ofhealth.

It can be said that the impact expectedfrom the services furnished to increase thelevel of community health depends funda-mentally on three different, but interde-pendent factors: the program, the coverage,and the resources.

Modern research techniques have, in thepast few years, greatly increased our knowl-edge of ways and means of preventing dis-ease and restoring and improving man'slevel of health. Unfortunately, the utiliza-tion of this knowledge to the degree neces-sary to obtain the desired results encount-ers serious obstacles because the practicalapplication is costly and complex.

Moral, political, and economic reasonsmake it necessary for the State to concernitself with the well-being of the populationin general as well as with that of certainspecific groups in particular, and thus toparticipate in the planning for, and distri-bution of, services for the prevention ofdiseases and the promotion and restorationof health.

In vast areas in the Americas it has beenobserved that the number of beneficiariesof both preventive and curative servicesrepresents but a portion of the population,frequently a much lower proportion than isnecessary or desirable.

On the other hand, in the light of thedemands of other sectors, it may not bepossible to obtain the optimum assignmentof human and financial resources which areneeded in the health sector to increase boththe geographic coverage and the totality ofprogram of activities required to achievehealth levels comparable to those of coun-tries with conditions different from those inLatin America.

A judicious selection of the measures andprocedures that are most highly productivein terms of decreasing morbidity and mor-tality will permit the formulation of a pro-gram ensuring a progressively increasingcoverage and maximum utilization of bothpresent resources and those which it ishoped may later become available.

A critical study of present programs maywell reveal the advisability of making acareful revision of projects in operation soas to correct, limit, and even interrupt thosethat are not in keeping with the healthpriorities of a country or region.

An inventory of human and material re-sources available might serve as a basis fora redistribution of responsibilities aimed atobtaining better utilization of these re-sources. Particular attention should begiven to the present network of curativeservices, especially hospitals, the benefit ofwhich could be greatly expanded if theywere to furnish community services throughoutpatient departments and if their pro-grams of action were modified to providepreventive services to both individuals andfamilies. The advantages which might beexpected from effective coordination, or bet-ter still, integration of preventive and cura-tive services furnished by the State, and atleast from the establishment of a harmoni-ous and cooperative relationship with otherinstitutions furnishing medical care to thecommunity or to a part of it, are self evi-dent. The establishment of the basis forformal coordination would require the re-vision of the pertinent laws and regulationsand possibly the enactment of legislation.

Experience has shown that the least ex-pensive and most effective results are ob-tained when preventive and curative serv-ices are organized at three levels at least-national, regional, and local-each under asingle direction and incorporating medicalcare as a part of basic health services. Itis very probable that the revision of prioritycriteria and the consequent change in the


content of the health program will indicatethe advisability of reorganizing the presentadministrative machinery, as well as of in-troducing modifications into the organiza-tional structure of the ministries so as toensure the implementation of highest pri-ority activities. On the other hand, the cam-paigns for the solution of certain healthproblems have produced or are about toproduce results. The responsibility for themaintenance of the gains of the special cam-paigns should, for economic reasons, be pri-marily transferred to the general network oflocal health services. The assimilation ofthese new activities, resulting from specialcampaigns for tuberculosis immunization,smallpox vaccination, yaws eradication, andthe present malaria campaign, makes itnecessary to plan the extension and enlarge-ment of these local health service programsto absorb the increased responsibilities.

Although very justifiable, the idea of full-time employment of health service person-nel has not been applied as is required bythe functions of certain professional groups.A careful study of the training received bythe technical staff of each country and theactual utilization of their services mightserve as a criterion for the assignment offunctions and the selection of posts thatshould be full-time and therefore enjoy cor-responding remuneration. Moreover, witha view to economizing time and effort ofpersonnel, it is desirable to revise the cur-riculum of local training courses for staffso as to adjust their content and durationmore closely to the needs of the services forwhich they are intended.

Worthy of mention are the serious dis-advantages that have been evident whenthe expansion of the health services net-work-especially hospitals-is not donegradually and progressively over the rea-sonable period required to permit imple-mentation with the necessary personnel andoperational budget. The huge investment inthe construction and equipping of these

services is not very productive unless theyare used to their maximum capacity.

Again in this field, it has been recognizedthat adequate statistical information, withparticular attention to data on resources,services, and results of programs and serv-ices, is essential.

There is evidence that the administra-tive machinery in many of the health min-istries in the Americas is inadequate tosupport the large and complex operationand to utilize existing resources effectively.The need for better administration andmanagement is declared at several points inthe Charter of Punta del Este and standsas an imperative.

In order to obtain maximum efficiency ofoperations, systems of administration mustbe adopted to provide for orderly planning,budgeting, and allotment and allocation offunds; career service conditions, full-timeservice, with recruitment and promotionbased on merit; full utilization of personneltrained at public expense; and establish-ment of supporting services required for theeffective utilization of technical and pro-fessional staff.

The principles of scientific managementshould be applied in the administration ofhealth services, with particular attention toorganizational structure, finance and budgetprocedures, personnel policies, procurementand supply functions, and the efficientoperation and maintenance of buildings andinstallations.

It is necessary to establish close coopera-tion between technical and administrativepersonnel at all levels. In view of the scar-city of well-trained professional personnel,the work must 'be organized so as to obtainthe greatest yield from professional skills.Adequate programming will make it possi-ble to obtain the maximum yield from pro-fessionals and auxiliaries. It is thus desir-able to review the techniques of in-servicetraining and of education at all levels.

Above all it is indispensable to create an

Final Report 27

administrative conscience and a sense ofresponsibility in all officials, in keeping withthe high purpose of the health services.

B.3 Education and Training

Resolution A.2 calls for action necessaryto increase the numbers and quality ofthe health manpower required to permitachievement of the goals of the Charter ofPunta del Este, as follows (par. 1-d):

To give particular importance to the educa-tion and training of professional and auxiliarypersonnel to engage in activities related to theprevention and cure of diseases. To this end itwvill be necessary:

(1) To determine the number of experts re-quired in the various categories for eachactivity or profession;

(2) To provide in-service training to presentstaff members, and progressively train a !minimum number of additional person-lnel; and

(3) To expand or create the necessary edu-cational centers.

Most Latin American countries currentlydo not have sufficient personnel available toprovide medical and health services to theirpeople. There is a deficiency in quantity,and especially in over-all technical prepara-tion.

Educational opportunities must be im-proved and increased in order to providepersonnel for public health services. Pro-fessional health workers will emerge prin-cipally from the ranks of those who enrollin schools of higher education to prepare fora career in one of the health specialities.The number of persons with secondary edu-cation must be increased, and better oppor-tunities for university studies must be madeavailable. At the same time, it is necessaryto greatly augment the number of auxiliaryhealth workers, who require less extensiveacademic education, especially in the fieldsof nursing and environmental sanitation.Measures for their training and supervision

are also part of the necessary planning tomeet health personnel needs.

In the case of physicians and others,faulty utilization of personnel is due prin-cipally to poor distribution. For example, inLatin America there is one physician forevery 2,000 persons. Relatively speaking,this is not an unfavorable figure. However,their concentration in the cities leaves aratio in the rural areas that is far fromdesirable. Each year some 8,000 physiciansare graduated, and are more and more ab-sorbed into municipal health services. Thediscrepancy between the type of trainingthey are given and the training they require

! must be reduced to a minimum. The phy-i sician's training should stress the relation-¡ ship of health and disease to the structure

and the organization of the community.This involves the essential principles ofhealth administration in addition to theusual training in basic and clinical sciences.

Graduate nurses in Latin America arescarce, owing to the lack of certain elementsfor the recruitment of candidates. Impor-tant among these are secondary educationfor women and facilities for professionaltraining. Salaries often are not equal tothose earned by women in other professionsfor which the same number of years oftraining is required.

Graduate nurses currently in service arein the approximate proportion of one per5,000 population, which does not permit theproper development of necessary nursingservices or adequate supervision of auxil-iary nursing personnel.

Surveys made in several countries onnursing resources have shown that at least50 per cent of nursing services are providedby auxiliary personnel who have receivedno formal training and are under no medicalor nursing supervision. In the rural areasof many countries, auxiliary nursing person-nel without formal training are frequentlyin attendance at activities traditionally car-ried out by physicians, such as attendance


at childbirth, minor surgery, or others, withconsequent greater risks.

It is therefore necessary to increase tothe greatest extent possible the number oftrained nurses who have special instructionin the techniques and methods of trainingand supervision of auxiliaries, and in healtheducation, without extending the trainingto longer than three years.

In the field of environmental sanitation,it is estimated that there are 2,000 sanitaryengineers in Latin America, or one for each100,000 persons. Currently about 100 sani-tary engineers are graduated each year inLatin America, and more are needed to de-velop environmental sanitation programs.Civil engineers and other professionals tak-ing part in these programs should be taughtthe basic principles of sanitation and healtheducation.

The programs of water supply for urbanand rural areas and the development ofother environmental health services nowrequire a better utilization of the servicesof professionals and, from the long-rangepoint of view, additional numbers of suchprofessionals.

As for sanitary inspectors, of whom thereare currently one for each 25,000 persons,the basic educational requirements have notalways been met. Training in the methodsand techniques of teaching and supervisioncould enhance the value of those who re-ceive formal training, and would increasethe potential capacities of the auxiliarysanitation workers.

Dentists and veterinarians in LatinAmerica exist in the ratio of one per 5,000and one per 50,000, respectively. These fig-ures represent only absolute numbers, andthe large urban areas absorb an excessiveproportion of these professionals.

The figures relating to subprofessionalpersonnel in general are even less favorable,and the needs in supervision are still greater.Consideration should be given to the needfor a good secondary educational back-

¡

ground for sanitary inspectors, nursing aux-iliaries, statistical auxiliaries, etc.

A close relationship and collaboration be-tween the public health, university, and ba-sic education institutions could solve someof the current problems. Collaboration be-tween professional schools and the minis-tries of health, which are the "consumers"of the product of those schools, could helpimprove that product and be an essentialstep in the development of health programs.

Constant liaison between governmentagencies responsible for health, for basiceducation, and for higher education is arequisite for planning for the human re-sources needed to improve health in theAmericas.

Since the physician assumes an executiverole in the program and is in charge ofguiding the other professional workers inthe health team, there is a need for thehealth ministries to collaborate more closelywith programs for the training of physiciansin Latin America.

The training of physicians should beconceived as a systematic process directedtoward specific objectives, an inseparablepart of any health program, and thereforethe object of careful planning. It thereforeseems advisable for a careful review to bemade of the present medical education pro-grams. This review, and the planning of thefuture activities of these educational cen-ters, should be made jointly by those whoare responsible for planning medical educa-tion, in close collaboration with representa-tives of the institutions providing medicaland health care in the countries. Whennecessary, the advice of national or inter-national agencies with experience in thefield should be sought.

This planning group would be responsiblefor drafting short-term or long-term plans;for determining the most pressing needs andavailable resources; and for indicating pri-orities. The training of physicians cannotbe dissociated from the "medical demand"

Final Report 29

of the population, from resources for train-ing physicians, or from maintenance of serv-ices in accordance with current knowledge.The planning group should analyze aspectsaffecting productivity and output, workingconditions, and the degree of satisfactionphysicians obtain from their work. Attitudesof paramedical personnel, the ratio of physi-cians to paramedical personnel, and the ad-ministrative organization of agencies re-sponsible for health care should also receiveattention. Nor can the attitude of the popu-lation toward sickness and health, and itsbehavioral response to medical services, beoverlooked.

It is often supposed that a higher physi-cian/population ratio means better medicalcare. This is not necessarily the case, sincethe utilization of medical services dependsalso upon social and economic factors. Infact, there is no evidence that an increasein the number of physicians in proportionto population, beyond a certain limit, willbe reflected in a lowering of the mortalityor morbidity rates of a community, or evenin better health.

The number of physicians required tocare for a population varies according tothe burden represented by disease, the or-ganization of medical care services, thenumber of nurses and auxiliary personnelavailable, and the varied social and eco-nomic factors that influence the utilizationof physicians' services.

It is not possible, at present, to suggestthe establishment of a single uniform ratioapplicable to all countries. Therefore, it isurgently necessary to determine the numberof professional medical personnel essentialfor each individual country. Use continuesto be made of ratios derived from countriesthat have a different culture, different waysof life, different political and administrativestructures, and that have already reacheda stage of consolidated economic develop-ment, unlike most of the Latin Americancountries. The quality of resources should

be taken into account, as well as the relativeurgency of medical and social problems.The solution of this problem requires acareful analysis of the medical resources ofeach country and of the trends and magni-tude of the medical demands of the popula-tion. Due attention should also be paid tothe productivity and output of the physi-cians, which in the final analysis is the pointof greatest interest.

The development of medical education isconsidered to be essential to the success ofprograms for the protection, promotion, andrestoration of health at the local level, aswell as in national health plans. This aspecttakes on special importance with the newefforts the Hemisphere is making to accel-erate economic and social development.

Indeed, in the health programs, in addi-tion to professional and technical work, thephysician accepts the role of leader, teacher,and guide for technical and paramedicalworkers, for other professionals, and foradministrative personnel. The physician'sposition is one of great responsibility, notonly because of his mission, but also be-cause of the resources entrusted to the tech-nical group which he heads.

Without sufficient competent physicians,no health program can be successful; there-fore, ministries of health and their com-ponents responsible for carrying out pro-grams should take an interest and collabor-ate in the basic and advanced training ofphysicians. For this purpose it would behighly desirable for closer relations to beestablished between the health ministriesand the medical schools. Ministries of healthare urged to give their moral support tomedical schools and, when possible, financialassistance essential for strengthening theirservices and their educational programs.Such cooperative efforts could assist theagencies responsible for health care to meettheir responsibilities to provide medical careto the population. In addition, medicalschools make a powerful contribution to the


improvement of health conditions throughtheir programs of scientific research.

In order to facilitate plans for the expan-sion of medical education, ministries ofhealth are urged to make all the resourcesunder their supervision available to medicalschools. This includes hospitals and healthcenters, which may serve as models becauseof the high quality of care they provideand their influence on the communities theyserve.

The ministries of health should also makeavailable duly selected urban and ruralhealth services in which to provide students,interns, and residents with practical experi-ence. This should be gained under the con-stant supervision of the professional staffof the institution and the teaching staff.Requiring that students face up to the realhealth situation in the rural areas wouldhelp intensify their sense of responsibilityand give them a broader view of medicine.It would also provide them with incen-tives, once they are graduated, to practicetheir profession in such areas. This couldhelp bring about a better distribution ofphysicians.

B'.4 Research

Resolution A.2 of the Charter of Puntadel Este emphasizes the contribution thatresearch can make to the health of theindividual and community, in the followingterms (par. l-g):

To make the best possible use of knowledgeobtained through scientific research for the pre-vention and treatment of diseases.

Any systematic program for health ad-vancement under the Alliance for Progressmust rely heavily on improved knowledgeof the life sciences, and medical, engineer-ing, and social research is needed to providethe necessary knowledge.

Basic fields of inquiry are the causes,treatment, and control of disease, the appli-cation of known principles and methods of

control of environmental conditions relatingto health, and the adaptation of existingknowledge of the provision of medical carewithin the socioeconomic context of differ-ent countries, regions, and localities.

The intensification and expansion of re-search in these fields depends on skilledprofessional and subprofessional manpower,which is in short supply in all fields ofresearch in the life sciences in the Americas.The overriding necessity, therefore, is tomobilize available scientific manpower forresearch within the framework of healthdevelopment in general and to accelerateresearch training programs for promisingprofessional personnel to meet future needs.Each Government should evaluate existingresearch and research training resourceswith the objective of expanding these re-sources to meet the requirements of healthprograms.

The utilization and coordination of re-search and training capabilities of schoolsof medicine, veterinary medicine, dentistry,public health, and sanitary engineering, andof research institutions and government de-partments should be encouraged.

Particular areas of research interestwithin the framework of the Alliance forProgress are the following: the control anderadication of communicable diseases andmalnutrition; engineering studies in thefields of environmental sanitation, housing,industrial hygiene, and air and water pollu-tion; economic and statistical studies of theorganization and administration of medicalcare and public health services; studies ofrequirements for professional and auxiliarymanpower in the health sciences.

Finally, it is important that research inthe biomedical, bioengineering, and bio-social fields be closely coordinated with theoperational and information requirementsof health services, health planning agencies,and the institutions engaged in the educa-tion and training of health personnel. Theeffectiveness and efficiency of health plan-

Final Report 31

ning and health service activities dependon the assembly of accurate basic healthinformation.

Research is needed to develop bettermethods for acquiring the necessary healthinformation data, and for its processing,analysis, and use in the administration ofall pertinent programs.

B.5 Increase in Life Expectancy at Birthby a Minimum of Five Years

during the Decade

The programs for construction of watersupply and sewage disposal systems, en-vironmental health, eradication and controlof communicable diseases, and improvementof nutritional status influence the state ofhealth of the population by the preventionof illness and death. In these programs thespecific goals established are to completethe eradication of malaria and smallpoxfrom the Hemisphere and to provide potablewater and sewage disposal systems.

One measure of the combined effect ofthe health programs and other advances forsocial progress is the reduction of mortalityand the extension of life.

In countries that have excessive deathrates, marked improvements through theextension of health programs, combinedwith socioeconomic developments, are usu-ally evident in an increasing life expectancyat birth. Reduction in mortality, especiallyof children under five years of age, producesa rapid increase in life expectancy, as isdemonstrated by data from Chile, Mexico,and Venezuela. By reducing the death rateunder five years in many of the LatinAmerican countries by one half, theoreti-cally the increase in the life expectancywould be five to six years. Since majorimprovements in environmental conditionsand nutritional status, and the extension ofprograms to prevent communicable diseases,would also reduce the number of deaths inolder children and adults, such progress

could be expected to increase life expectancyat birth by five to 10 years.

For the calculation of life tables, it isnecessary to have accurate census data onthe population, by age, as well as data ondeaths, by age, obtained from the registra-tion system. These statistical data are es-sential for many aspects of the planningand evaluating of programs, and for devis-ing the instruments to measure the resultsof programs. Censuses have not been takenin seven countries of the Americas in theperiod around 1960. Thus, the populationbase for the calculation of a life table isnot available. These censuses should betaken as soon as possible in order to obtaindata for many phases of planning for socialand economic progress.

Unfortunately, registration of deaths isincomplete in many areas of the Americas;moreover, deaths in infancy and early child-hood are not as well registered as those inother age groups. Therefore, careful plan-ning should be carried on in each countrywith a view to obtaining an accurate meas-urement of mortality at the present time.Representative areas which adequate stud-ies have determined to have good death andbirth registration should be selected. Ifregistration is incomplete, corrections needto be applied to existing death rates in orderto obtain an estimate of the life expectancyat birth which represents the true situationat the beginning of this decade.

Thus, in each country efforts should bedirected at once to obtaining the populationfigures from the census as well as correcteddeath rates for use in calculating a life tablefor 1960 or 1961, or as early as possible inthe 1960's.

In addition to the establishment of thebaseline-life expectancy at the beginningof the period-sound planning includes thecurrent and continuing development of es-sential data for measurement of progressthrough the decade.

From the deaths by age group, a selection


will be made of those groups whose mor-tality differs most from that in countrieswhich are more advanced from the view-point of health. Once these groups havebeen determined-and they include espe-cially those under five years-a study willbe made of the principal causes of death,either on the basis of all death certificatesor by sampling other sources, if necessary.

Among the diseases constituting the prin-cipal causes of death, a selection will thenbe made of those for which effective proce-dures exist. In this way the health programmay be directed against these specific causesof death, a procedure that will yield benefitsfar more quickly than has been possibleheretofore.

Provision should be made for a censusin each country in or around 1970. In therepresentative registration areas, proceduresshould be established to ensure satisfactoryregistration of births and deaths, and suchmethods should be extended as rapidly aspossible to the entire country. By the endof the decade, it is hoped that both censusand registration data will be available foraccurate assessment of progress.

The goal of increasing the average lifeexpectancy at birth by five years in thedecade appears to be a practical and usefulmeasure of the success of programs for theimprovement of health conditions in theAmericas.

VII. RECOMMENDATIONS

A.1 Malaria Eradication

i. In large areas of the Americas, thepresence of malaria is still an importantnegative factor in relation to the attainmentof the short-term and long-term economicand social objectives approved by the Gov-ernments in the Act of Bogotá and amplifiedin the Charter of Punta del Este. Conse-quently, it is imperative that the Govern-ments continue to give fundamental pri-ority to the malaria eradication campaigns.

ii. Larger financial resources are neededto intensify antimalaria activities and theirevaluation. It is advisable that the inter-national institutions increase their contri-bution and that the international banksoffer the Governments the necessary credits.

iii. It is essential to improve the admin-istration of the eradication campaign, inorder to give it greater flexibility and speedin action. It is advisable to avoid interfer-ence by outside interests insofar as possible.

iv. Closer coordination between the ex-isting health services and the malaria eradi-

cation programs is to be recommended; al-though such coordination must be estab-lished from the beginning of antimalariaactivities, it becomes even more essentialin the consolidation phase.

v. It is highly advisable that the coun-tries affected by malaria aid each other re-ciprocally, through interchange of resourcesand/or regional use of these resources, espe-cially in border areas of difficult access.

vi. The training of a larger number ofepidemiologists and entomologists having afirm scientific and biological foundation isessential.

vii. It is suggested that the productionof new insecticides that have prolongedresidual action, as well as of antimalariadrugs that have a radical curative and pro-longed suppressive effect, continue to beencouraged.

viii. It is recommended that further re-search be done with a view to clarifying themechanism of action of insecticides and itsrelation to the phenomenon of insect re-sistance.

Final Report 33

ix. It is suggested that UNICEF, andother organizations that have been con-tributing funds to the eradication campaign,be requested to continue their contributionsuntil the Pan American Sanitary Bureaucertifies that eradication has been completed.

A.2 Tuberculosis

i. The Governments should take the nec-essary measures to intensify tuberculosiscontrol in accordance with Resolution A.2of the Charter of Punta del Este, and togive it the priority it deserves in a nationalhealth program.

ii. The Governments should orient theantituberculosis programs toward the ap-plication of the simplest and cheapest mod-ern diagnostic, treatment, and prophylacticmethods to the greatest number of people,the basic idea being that, since it is a com-municable disease, efforts should first bedirected at breaking the chain of trans-mission.

iii. The Government should recognize theimportance of incorporating the antituber-culosis services into the general health serv-ices, including the so-called medical careservices, and should facilitate this integra-tion as a practical way of maintainingtuberculosis control as a continuous, long-term activity.

iv. The Government should increase thetraining of the physicians of the health serv-ices in the techniques of diagnosis, treat-ment and chemoprophylaxis, in the interpre-tation of epidemiological information, andin the administration of antituberculosisprograms within the general health services.They should also increase the training ofthe auxiliary personnel of the general healthservices in the specific techniques employedin the prevention and control of tubercu-losis. This training is urgently needed inorder to be able to cope with the problem,but it also represents an important steptoward the integration of the health services

and the implementation of the program withnon-specialized personnel.

v. The Governments should ensure thatthe necessary budgetary allocations willbe provided for carrying out their anti-tuberculosis programs, which are long-termprograms, and they should encourage com-munity cooperation in specific activitiescomplementary to the national program.

vi. Considering that tuberculosis controlrequires ample resources of funds and per-sonnel, it is especially requested that theinternational organizations intensify theircooperation in both technical assistance andthe provision of funds to expand the controlprograms throughout Latin America.

A.3 Smallpox Eradication

i. The Governments of the countrieswhere foci still exist should intensify andaccelerate their national programs of small-pox eradication, give them a high prioritywithin national health plans, and seek suchadditional funds and resources as are neededfrom national and international sources.

ii. The Governments that have alreadyeradicated smallpox should establish pro-cedures within their health services whichwill guarantee the maintenance of adequatelevels of immunity, as well as continuedvigilance to avoid possible recurrence of thedisease. This can be accomplished throughthe annual vaccination of one fifth of thepopulation.

iii. The Governments should coordinatetheir efforts and assist each other in devel-oping programs of smallpox vaccinationaimed at eradicating smallpox in the Ameri-cas in the shortest possible time. Collabora-tion among countries is of special impor-tance in border areas.

A.4 Chagas' Disease

i. It is recommended that at the end ofthe malaria eradication program the spray-


ing teams undertake spraying programs forthe purpose of eradicating or diminishingtriatomes in the houses, especially in thosewhere, as a consequence of the insecticidesused in the eradication of malaria, the den-sity of such insects has increased; suchsprayings should be extended to other areasinfested with the vectors of Chagas' disease.Community cooperation should be requiredfor such programs.

ii. It is recommended that, in the coun-tries where the magnitude of the problemof Chagas' disease is still not known, epi-demiological surveys be undertaken as apart of the regular activities of the healthservices and, if necessary, in cooperationwith university research institutions.

iii. It is recommended that, with inter-national cooperation, the Governmentsstrengthen and expand research on thepathogenesis, diagnosis, epidemiology, andtreatment of Chagas' disease.

iv. In view of the relationship betweenpoor housing and Chagas' disease, it is sug-gested to Governments that housing agen-cies give special priority to programs of re-placement, repair, or refitting of houses inareas where triatomes are prevalent. Ruralcommunities, properly organized and in-formed, should participate actively in therepair and improvement of their housing.

v. It is recommended that internationalcooperation be utilized for present and fu-ture programs for control of the vectors ofChagas' disease.

A.5 Nutrition

i. It is suggested that ministries of healthshould establish minimum standards foradequate nutrition of the population, bothfor the individual and for the total popula-tion, and that on this basis agriculturalpolicies with respect to livestock and othersources of food production should be ration-alized in order to assure the fulfillment ofthese requirements.

ii. It is recommended that ministries ofhealth should participate actively in theplanning and development of nutrition pro-grams and that nutrition should be effec-tively integrated into health programs insuch a manner as to become a basic serviceat the local level.

iii. It is recommended, in order that na-tional nutrition programs may be more ef-fective, that a greater degree of coordinationshould be established between the health,agricultural, and education services as wellas with other national and internationalagencies.

iv. It is recommended that the educationin nutrition of personnel at all levels beconsiderably increased in order that suchpersonnel may work in applied nutritionprograms at regional and local levels.

v. Environmental sanitation programsmust give more attention to the control ofrodents and insects which cause losses infood storage, and greater efforts must bemade to control enzootic diseases in orderto achieve greater production of animalproteins.

vi. It is suggested that Governments in-troduce and implement practical legislationwith reference to salt iodization and cerealenrichment.

vii. It is recommended that Governmentsincrease their research and studies on themass production, distribution, and utiliza-tion of new sources of inexpensive foods,especially those with a high protein value.

viii. It is suggested that Governmentsconduct studies to acquire information onfood consumption as well as on nationalfood production.

A.6 Environmental Sanitation

i. Among health programs the highestpriority should be given to environmentalsanitation and, within this field, to watersupply and sewage disposal systems in urban

Final Report 35

and rural areas of Latin America. Thispriority should be reflected in the programsof national development, especially as re-gards the allocation of funds and the es-tablishment of the agencies necessary toachieve the objectives set forth in the Char-ter of Punta del Este.

ii. Programs for the construction of wa-ter supply and sewage disposal systemsshould be intensified to the maximum inurban areas; they should be self-financingthrough the establishment of rational ratesand should be well organized and adminis-tered. The ministries of health should stimu-late and coordinate their activities withthose of other national or local agencies incharge of urban water supply and sewagedisposal services.

iii. In order to fulfill the objectives ofthe Charter of Punta del Este in ruralareas, the Pan American Health Organi-zation should study the possibility of es-tablishing a Special Fund, which mightbe called the Rural Welfare Fund, to befinanced by contributions from the countriesthemselves, from the Alliance for Progress,and from other international agencies. ThisFund would make it possible for Govern-ments to draw up and carry out environ-mental sanitation projects, with the co-operation of organized communities, pri-ority being given to water supply projects.

The ministries of health will be thoseresponsible for the programming and execu-tion of rural sanitation works. They couldlend or assign organized communities thenecessary funds for such works. It is be-lieved that, with a suitable installment sys-tem, a high percentage of the capital outlaycould be recovered and used as a revolvingfund that could benefit other communities.

iv. Rural environmental sanitation pro-grams should be initiated in areas wherethere is the greatest concentration of popu-lation and where the system could servegroups of houses. When the economic condi-

tion of the community permits, it would bepossible to carry the water lines into thehouses; the ministries of health could -beresponsible for the domiciliary connections.

v. It is recommended that environmentalsanitation units be given sufficient authorityto permit them to exercise their proper ad-visory functions within the ministry ofhealth, and also those of coordination andsupervision of all governmental bodies thatare also responsible for such works.

vi. The ministries of health should takean active part in the planning and execu-tion of housing programs sponsored by theGovernments, especially those that are de-veloped in rural areas, and in the matterof the construction or improvement of hous-ing, they should encourage self-help effortsand the development of cooperatives toachieve this objective.

vii. The ministries of health should in-tensify occupational health programs aswell as those for the control of water andair pollution. Special attention should begiven to the protection of the agriculturalworker against occupational hazards, espe-cially those inherent in modern agricul-tural practice. Industrialization programsshould include industrial safety and healthmeasures.

viii. It is suggested that internationalbanking agencies include in their loan con-tracts to public or private enterprises aclause providing for measures to reducework hazards, in accordance with the legis-lation of each country. It is requested thatthe Pan American Sanitary Bureau under-take the pertinent negotiations.

ix. The urgent need for the training ofprofessional and subprofessional personnelin the field of environmental sanitation isrecognized to be of the utmost importance.It is recommended that the internationalagencies award the largest possible numberof fellowships for this purpose and collabo-

1


rate in the training of experts in thecountries.

B.1 National Planning for Health

i. It is essential that the Governmentsproceed to establish planning and evalua-tion units within the ministries of health,staffed by specially trained personnel. Theseunits should be represented in the nationalagencies or commissions for developmentplanning, if possible with the personal par-ticipation of the Minister of Health or hisdelegates.

ii. The necessary changes in health or-ganization and administration should bemade in order to guide the process of plan-ning through the technical and administra-tive channels it requires. This involves ad-ministrative rationalization of the services;training and proper utilization of personnel;improvement of the financial systems; andpreparation of program budgets.

iii. Changes and improvements should bemade in the statistical systems in order toadapt the collection of data and their anal-ysis to the requirements and methodologyof planning. For this purpose, it is recom-mended that the ministries of health havestatistical units at the most appropriatelevel. The advisability of taking populationcensuses, of improving vital and hospitalstatistics, and of preparing statistics onresources and other basic elements is em-phasized. However, it is accepted that plan-ning should be undertaken at once, with thepresently available data, even though theyare insufficient, and without waiting forthe improvement of the statistics or thetaking of censuses. Attention is called tothe desirability of finding indices whichwill make it possible to express the relativevalues of each program objectively, withoutforgetting that, since what is aimed at isthe improvement of health, the indices usedshould basically be those which will indi-cate progress toward that goal, and not

merely represent indices of administrativeobjectives.

iv. It is recommended that "registrationareas" which cover a representative sampleof the population, and in which it will bepossible to organize the collection and anal-ysis of vital and health statistics, be selectedin each country; these data will serve as abasis for formulating national plans andcalculating life expectancy.

v. The training of the personnel in plan-ning should be intensified. Not only mustexperts responsible for formulating the plansand evaluating them be trained, but themethodology must be taught to all the per-sonnel participating in the planning process.

vi. The Governments should define ahealth policy suitable for the country inthe light of the development plans, thegrowth of the population, and other factors.

vii. Systematic planning for the nationalterritory should be undertaken; it shouldbe studied area by area, an appraisal of thesituation in each of these areas should bemade, the priorities of the problems shouldbe defined, and the most suitable or feasiblesolutions should be put forward and sub-mitted to a higher level for decision.

viii. The Governments should conduct re-search in experimental areas in coordinationwith the universities in order to gain a moreaccurate knowledge of the nature of theproblems, of the standards that should beadopted in accordance with the existing na-tional conditions, of the best way to takefull advantage of the resources the countryhas available, of the attitude and responseof the community, and of other aspectsessential to planning on a national scale.

ix. Such is the importance and variety ofhealth needs as compared with the limitedresources available to meet them, that theymust be arranged according to prioritieswhich themselves should be established,during the planning process, in the light of

Final Report 37

all the considerations indicated by thenational interest.

The criteria for establishing priorities areindicated in Part IV of this report.

x. It is recommended that the Govern-ments complete their national economic andsocial development plans, including the pub-lic health program, as soon as possible, sothat the over-all plan may be submitted, ifthey so desire, to the evaluation procedureof the Organization of American States, inorder that this plan, and especially thehealth program, may be put into operationwith their own resources and with necessaryexternal financial aid.

B.2 Improvemnent of Health Services

i. In planning for new services or forthe expansion of existing ones, it is recom-mended that a study and analysis be madeof existing programs. It is further recom-mended that an inventory of personnel, fa-cilities, and budget be made so as to beable to develop programs which will givethe greatest yield in terms of reduction ofmorbidity and mortality.

ii. Special campaigns carried out by thecentral level are necessary under certaincircumstances. However, it is recommendedthat they be incorporated within the frame-work of the general health services at theearliest possible stage of development.

iii. It is necessary, when planning forthe expansion of health services, especiallyin the case of medical care, to take intoaccount not only the cost of constructionand equipment, but also the quantitativeand qualitative personnel requirements andthe budget for operation. Such expansionshould be prudently phased; at the sametime, existing resources should be fullyutilized. Construction plans should form anelement of national health plans.

iv. The ministries of health should takesteps to secure the legal and institutional

instruments required for the effective co-ordination of the planning and executiveelements responsible for preventive andcurative services of the State, as well ascoordination between these and private,semiautonomous, and autonomous organi-zations providing health services of anytype. The aim is to incorporate the medicalcare activities of those institutions, includ-ing hospitalization, into the basic healthservices at all levels-local, intermediate,or national-with the final objective ofattaining a progressive integration of theseactivities. Preventive and curative servicesare but parts of an integrated whole.

v. It is recommended that the regionali-zation of services be promoted on the basisof technical resources adequate for theprotection, promotion, and restoration ofhealth.

vi. It is recommended that national andinternational sources of financing adapttheir loan policies to the characteristics ofthe health sector, and adjust their require-ments to the stages planned by healthagencies.

vii. It is suggested that Governmentstake steps to review and revise legislationand related administrative instruments soas to provide a legal structure which willpermit the most effective utilization of theresources now available, as well as thosewhich may later become available to coun-tries through the Alliance for Progress.

The specific measures which are recom-mended are:

a. Critical review of administrative struc-ture and procedures, including budget andfiscal practices, and their relation to na-tional health needs, programs, and resourcesin order to assure the best use of the fundsbudgeted for health as well as of personneland services.

b. Adoption of modern techniques andtools of management, such as programbudgeting, mechanical systems, etc.


c. More effective use of administrativepersonnel along with technicians in theformulation, execution, and evaluation ofprograms.

d. Establishment of career and meritsystems for health service personnel.

B.3 Education and Training ofProfessional Health Personnel

i. A more detailed study of current hu-man resources in the field of health, and theplanning of both short-term and long-termneeds, are required.

The basic short-term need is to obtainbetter utilization of human resources toachieve objectives, together with planningand establishment of necessary prioritiesat the national level. All this includes healthand educational institutions. Supervisionand training of auxiliary personnel and theavailability of educational supplies andequipment are essential.

Long-term requirements are increasedquantity and better preparation of profes-sionals, as well as their distribution in keep-ing with the needs of the urban and ruralpopulation. Better utilization of resourcescan be achieved by maintaining greaterflexibility in the movements of personnel.As to subprofessional personnel, academictraining as well as better quality of super-vision are deemed fundamental for thecarrying out of national public health plans.

Methods for financing the provision andutilization of resources and facilities arepart of the planning for the education andtraining of personnel to be utilized by thepublic health services.

ii. It is recommended that interagencycommittees be established, representingministries of education, authorities of uni-versity schools, public health leaders, andrepresentatives of organized professions, tostudy the training of professionals requiredfor health programs.

iii. It is recommended that the conceptof the relationship of health and disease tothe structure and organization of the com-munity, as applied in public health admin-istration, be incorporated into the teachingprograms of university schools that trainpersonnel who will work in the health field.

iv. It is recommended that primary andsecondary education incorporate into theircurricula the basic ideas of health promo-tion, as a means of facilitating the trainingof auxiliary personnel for health services.

v. It is suggested that closer coordinationbe established between ministries of health,ministries of education, and the universities,in order to improve financing and to ensurethat the functions of medical schools aremore in line with the health needs of thecountries.

vi. It is suggested that medical schoolsbe encouraged to plan their work programsin collaboration with ministries of health,in such a way that the teaching offeredincludes a more balanced presentation ofthe curative aspects of medicine and ofthose related to disease prevention andhealth promotion.

vii. It is recommended that health minis-tries cooperate with medical schools byproviding means whereby hospitals andhealth centers may serve as institutions ofapprenticeship in medicine in the broadestsense.

viii. It is essential that ministries ofhealth collaborate with medical schools toextend their teaching functions to thepostgraduate period through residencies inhospitals and public health institutions,programs of specialization and training incertain medical disciplines, and refreshercourses to keep practicing physicians abreastof advances made in medicine.

ix. It is suggested that studies be carriedout to serve as a guide for obtaining a bettergeographic distribution of physicians.

Final Report 39

x. Ministries of health and universityschools should collaborate in medical edu-cation programs directed toward the train-ing of teaching staff for medical schools.

__ TL :- ---_ 1 1 .

economic, administrative, and statistical as-pects of the programs and services requiredto promote and protect individual and com-munity health.

xi. It is essential to promote and en- iv. Research programs in the medical,courage joint research work by ministries social, and engineering fields should beof health and medical schools in order to planned with full knowledge and attentionfind solutions to the health problems that to the operational requirements of healthare of greatest importance in the various services, health planning units, and the in-countries. stitutions engaged in the education and

xii. It is urgently necessary to promote training of health personnel.the establishment of education and training v. It is recommended that programs becenters for developing teaching staff, at alled to assure rapid dissemination oflevels in our countries, with financial con- research information, that fuller use betributions from. the Governments of the made of existing facilities, and that newHemisphere and from private or intergov- systems be developed, if necessary.ernmental institutions whose programs in-clude medical training. vi. It is suggested that necessary steps

xiii. It is suggested that full advantagebe taken of the fellowship programs offeredby international organizations, and that thecountries give priority to fellowships forhealth studies.

B.4 Research

i. It is recommended that Governmentsmake an assessment of their national re-search and research training resources inthe health sciences, and give appropriateattention to expanding these resources tomeet the requirements related to healthpriorities established in national develop-ment plans.

ii. The research resources for healthshould be directed toward the solution ofsocial problems which have been given thehighest priorities for action by nationalplans.

iii. It is desirable that ministries of healthincrease research activities, in accordancewith the objectives established in the Char-ter of Punta del Este, in the fields of con-trol and eradication of communicable dis-eases, nutrition, environmental sanitation,housing, occupational health, as well as in

be taken to assure exchange of informationon programs of research, training of re-search manpower, construction and equip-ment of facilities, and on financing bynational and international agencies, gov-ernmental and nongovernmental, so as topermit appropriate coordination of effortsand maximum utilization of all resources.

vii. It is suggested that programs of ap-plied research be developed to establishrealistic national and international stand-ards for manpower needs and utilization,construction of health facilities, etc., forthe guidance of both the health adminis-trators and the planning and fiscal agencies.

B.5 Increase in Life Expectancy at Birthby a Minimum of Five Years

during the Decade

i. The Task Force on Health at the Min-isterial Level recommends that the MemberGovernments obtain accurate data on popu-lation and on mortality rates. If registrationis not complete, representative birth anddeath registration areas should be estab-lished in each country. Life tables for largerepresentative registration areas, based on


accurate mortality and census data, arepreferable to those for the entire countrywhen there are deficiencies in registration.

ii. It is recommended that completenessof registration be determined in each coun-try and that programs which envision com-plete coverage of the country by 1970 beundertaken. The Pan American Health Or-ganization is requested to explore the pos-sibility of support for this activity frominternational sources and from the Alliancefor Progress.

iii. It is recommended that health pro-grams based on specific and direct measuresshould attack the diseases responsible forthe excessive mortality in children underfive years of age, such as gastroenteritis, re-spiratory diseases, measles, whooping coughand other infectious diseases, and nutri-tional deficiency, which constitute the prin-cipal causes of death in this group andwhich are more responsive to public healthmeasures, in order to accelerate the attain-ment of the goals.

iv. It is recommended that full supportbe given to the improvement of vital andhealth statistics essential for planning andfor the annual measurement of progress.It must be recognized that health progresscan be accurately measured only throughsound biostatistical methods and the useof reliable and complete vital statistics.

C.1 Latin American Common Marketfor Biological Products

The Task Force on Health at the Minis-terial Level, considering that it is essentialfor the health care of the people of theAmericas that all countries have availableto them biological products for the diagno-sis, prevention, and treatment of certainhuman diseases:

i. Recommends that the capacity of gov-ernment agencies to produce such biologi-cals be increased as soon as possible, in

accordance with the continental needs, andthat the interchange of such products bebegun immediately.

ii. Recommends the establishment of re-gional laboratories to set standards andcarry out necessary studies and researchfor quality control and for the manufactureof such new products as may be necessary.

iii. Recommends that technical and aux-iliary personnel be prepared and trained forthis purpose.

iv. Recommends that Governments elim-inate customs duties and excise taxes inorder to facilitate the free interchange ofthese products, when they are needed fornational public health programs.

v. Recommends that the Director ofthe Pan American Sanitary Bureau takethe necessary technical and administrativemeasures to put this program into effect.

vi. Recommends that, once the inter-change of biological products for humanuse has been established, efforts be madeto initiate a similar program for veterinaryproducts.

C.2 Quality and Cost of Essential Drugs

The Task Force on Health at the Minis-terial Level, deeply concerned over theobvious disparity between the high priceof drugs and the low purchasing power oflarge sectors of population in the Hemi-sphere, which creates a serious health prob-lem and impedes the execution of preventiveand curative health programs:

i. Recommends that an impartial tech-nical study be made by the Governmentsso as to enable them to gain a clear pictureof the costs involved in the production, dis-tribution, and sale of drugs.

ii. Recommends that industry be stimu-lated, through legislative and administra-tive measures, to produce essential drugswhich, while of optimum quality, can be

Final Report 41

produced, distributed, and sold at substan-tially reduced prices.

iii. Recommends that an active campaignbe initiated to improve the flexibility and;the technical quality of systems for thecontrol of drugs, in the course of both pro-

iduction and marketing, in order to assurepurity, therapeutic efficacy, and quality.

iv. Recommends that current legislationgoverning the control of drugs be revisedin the light of the needs of each country.

C.3 Role of Women in the Ten-Year PublicHealth Program of theAlliance for Progress

The Task Force on Health at the Minis-terial Level, considering that the activeparticipation of women in national healthplans is essential, since they are the centralpoint of the family; and that the Charterof Punta del Este recognizes that the par-ticipation of women in the formulation andexecution of social and economic develop-ment plans is essential to the attainment ofthe objectives of the Alliance for Progress:

i. Recommends to the Governments ofthe Americas and to inter-American andinternational organizations that, in all ac-tivities aimed at the execution of the Ten-Year Public Health Program of the Alliancefor Progress, full consideration be givento the contribution that can be made bywomen.

ii. Recommends to the Governments andto inter-American and international organi-zations, both governmental and nongovern-mental, interested in or concerned with

problems of the family, of women, or ofchildren, that they exhort their members towork more actively and positively towardthe solution of public health problems.

C.4 National Committees for theAlliance for Progress

The Task Force on Health at the Minis-terial Level, considering that the Organiza-tion of American States, in accordance withResolution E of the Charter of Punta delEste, is carrying out a public informationprogram aimed at promoting the interest ofthe peoples of the Americas in the Alliancefor Progress; that one of the measuresadopted is the establishment of NationalCommittees for the Alliance for Progress, inthe Member States of the OAS; and thatthe Charter of Punta del Este points out theintimate relationship and interdependencebetween economic and social developmentand the improvement of health conditions:

Recommends to the Organization ofAmerican States and the Governments ofthe Member States that, when establishingNational Committees for the Alliance forProgress, they take into consideration theadvisability of including representatives ofthe ministries of health in such committees.

C.5 Coordination with InternationalOrganizations

The Task Force on Health at the Minis-terial Level suggests that international or-ganizations should program their activitiesand coordinate their efforts in relation to thenational plans of the Governments.

VIII. FINAL DECLARATION

One fact has dominated the spirit of allthe participants in the Task Force onHealth: the great hopes of the people ofthe Americas and the sense of urgency to see

the promises of the Charter of Punta delEste fulfilled. The people are not satisfiedwith what they have; they think of whatthey could have, and they do not want to


wait for the hour indicated in the slowcourse of history. This aspiration is the hopeof the future; it is the clamor of the pres-ent. The success of this hemisphere-wideundertaking will depend upon the convictionwith which we hold to our conceptions andideals and upon the firm and determinedwill to carry them out within the period thathas been set.

In our discussions we have been alive tothe historic meaning of this Meeting. Sincethe International Sanitary Convention, inDecember of 1902, at which the Pan Ameri-can Sanitary Bureau was created, there hasnot been another occasion in this century, inthe Americas, in which the highest authori-ties in the field of health have met to dis-cuss purely technical matters of such im-portance to our time. Perhaps there has beenno other occasion when the importance ofman, on whom all the efforts of society arefocused, has been more clearly brought out.Those who have the moral authority to doso, have pointed out the humanitarian coreof every economic system and never before,either in the Hemisphere or in this century,has a sense of national purpose been mademanifest through the recognition of healthas a fundamental factor in social progressand economic development.

In the light of the Charter of Punta delEste, we have considered health in theAmericas in its technical, social, economic,juridical, and cultural aspects. The impor-tant advances made have been examined,the present problems have been defined, andthose that should have priority have beenselected. We have recommended a numberof practical measures for fulfilling the healthobjectives of the Charter. Their executionwill mean greater well-being; failure tocarry them out may lead to discouragementor frustration.

In the field of health this veritable chal-lenge takes on the most tragic proportions.The motivation exists or is latent; it canonly be intensified or stimulated by con-

crete activities of such scope that they willbring home to the people both the magni-tude of the effort and the basic fact thathealth is a good the conquest of which willenable them to attain their aspirations. Inthat conquest, man is the protagonist andthe only beneficiary of development.

From this analysis we have concludedthat the Ten-Year Public Health Programof the Alliance for Progress can be carriedout, provided its objectives are integratedin a rational way with the other goals thatour countries propose to reach and that thepotential resources of each and every oneof our countries, and our wills, are mobilizedto the full in the service of a higher ideal:the attainment of well-being for the benefitof all the people of America.

This noble task must be accomplishedfor the sake of the dignity of the people ofAmerica, in whom resides the destiny of theHemisphere at this singular hour in history.

IN WITNESS WHEREOF, the Ministers ofHealth of the signatory countries of theCharter of Punta del Este, or their repre-sentatives, and the Director of the PanAmerican Sanitary Bureau, Secretary of theMeeting, sign the present Final Report inthe English and Spanish languages, bothtexts being equally authentic.

DONE in Washington, D. C., United Statesof America, this twentieth day of Aprilnineteen hundred and sixty-three.

SIGNATURES:

ARGENTINA-Dr. Tiburcio Padilla, Minis-ter of Social Welfare and Public Health

BOLIVIA-Dr. Francisco. Torres Braca-monte, Representative of the Ministerof Public Health

BRAZIL,-Dr. Paulo Pinheiro Chagas,Minister of Health

CHIL-Mr. Benjamin Cid, Minister ofPublic Health

COLOMBIA-Dr. José Félix Patiio, Min-ister of Public Health

Final Report 43

COSTA RICA-Dr. Max Terán Valls, Min-ister of Public Health

DOMINICAN REPUBLIC-Dr. Sarmuel Men-doza Moya, Secretary of State forHealth and Social Welfare

ECUADOR-Dr. Luis Pallares, Minister ofSocial Welfare, Labor, and Health

EL SALVADOR-Dr. Ernesto R. Lima, Min-ister of Public Health and Social Wel-fare

GUATEMALA-Dr. Roberto Arroyave, Rep-resentative of the Minister of PublicHealth and Social Welfare

HAITI-Dr. Louis Mars, Representativeof the Secretary of State for PublicHealth and Population

HONDURAS-Dr. Carlos A. Javier, Repre-sentative of the Secretary of State forPublic Health and Social Welfare

MEXICO-Dr. José Alvarez Amézquita,President of the Meeting, Secretary ofHealth and Welfare

NICARAGUA-Dr. Constantino MendietaRodriguez, Representative of the Min-ister of Public Health

PANAMA-Dr. Bernardino González Ruiz,Minister of Labor, Social Welfare, andPublic Health

PARAGUAY-Dr. Dionisio González Torres,Minister of Public Health and SocialWelfare

PERU-Dr. Victor Solano Castro, Min-ister of Public Health and Social Wel-fare

UNITED STATES OF AMERICA-Dr. James

Watt FOR Dr. Luther L. Terry, SurgeonGeneral

URUGUAY-Dr. Aparicio Méndez, Minis-ter of Public Health

VENEZUELA-Dr. Arnoldo Gabaldon,Minister of Health and Social Welfare

Pan American Sanitary Bureau-Dr.Abraham Horwitz, Director, Secretaryof the Meeting

Addresses by the

Participants

ADDRESS BY THE SECRETARY GENERAL OF THE ORGANIZATIONOF AMERICAN STATES

DR. JOSE A. MORA

Presented at the First Plenary Session15 April 1963

On behalf of the Organization of Ameri-can States, it is my privilege to extend toyou a cordial welcome on this occasion ofthe inauguration of the Special Task Forceon Health, which is meeting to work towardthe achievement of one of the fundamentalgoals of the Charter of Punta del Este. Mostsignificant and of special importance is thefact that this Meeting of Ministers ofHealth is being held during Pan AmericanWeek. This week is the symbol of the unityof the Republics of the Americas and com-memorates the anniversary of the First Con-ference of our community of free nationsheld in this same city of Washington in theyear 1890.

That first Conference marked the be-ginning of the inter-American system. Fromthat time onward our Organization has im-proved continuously; it has established therole of law in inter-American relations,made it the mutual obligation of the Ameri-can States to maintain peace and security,and striven to induce respect for humanrights.

RELATIONSHIP BETWEEN ECONOMICDEVELOPMENT AND SOCIAL PROGRESS

To these accomplishments in the politicalsphere are now added the responsibility ofproviding the peoples of the Americas witha better and fuller life. Aware of this re-sponsibility, and inspired by the principlesset forth in Operation Pan-America and inthe Act of Bogotá, the American Republicson 17 August 1961 signed the Declaration

to the Peoples of America and the Charterof Punta del Este, which approved the Alli-ance for Progress. That Alliance was con-ceived as a great cooperative effort of thepeoples and Governments of the AmericanRepublics to accelerate the economic andsocial development of the countries of LatinAmerica so that they might achieve maxi-mum levels of well-being, with equal oppor-tunities for all, in democratic societiesadapted to their own needs and desires.

In April 1959 the Special Committee toStudy the Formulation of New Measures forEconomic Cooperation, in Resolution VIIadopted at Buenos Aires, recommended thatGovernments, in planning and negotiatingthe financing of their economic develop-ment, should include public health programsessential and complementary to their eco-nomic programs.

The Act of Bogotá, signed in 1960, ad-vanced matters even further and establishedthat measures for social improvement andeconomic development as part of the generalprocess should be simultaneous, comple-mentary, and progressive.

The high humanitarian ideals which in-spired the Declaration to the Peoples ofAmerica and the Charter of Punta del Este,in defining the objectives of the Alliance forProgress, echoed the same aspirations asthose already voiced in Operation Pan-America and in the Act of Bogotá. With

all these efforts, the American Republicshave for the first time in their history rec-ognized the close and mutual interrelation-

47

48 Addresses by the Participants

ship between economic development andsocial progress.

HEALTH-AN IMPORTANT OBJECTIVE OF

THE ALLIANCE FOR PROGRESS

The Charter of Punta del Este, in defin-ing the main objectives of the Alliance forProgress, included the following in Title I,item 8:

To increase life expectancy at birth by a mini-mum of five years, and to increase the ability tolearn and produce, by improving individual andpublic health. To attain this goal it will be neces-sary, among other measures, to provide adequatepotable water supply and sewage disposal to notless than 70 per cent of the urban and 50 percent of the rural population; to reduce thepresent mortality rate of children less than fiveyears of age by at least one half; to control themore serious communicable diseases, accordingto their importance as a cause of sickness, dis-ability, and death; to eradicate those illnesses,especially malaria, for which effective techniquesare known; to improve nutrition; to train medi-cal and health personnel to meet at least mini-mum requirements; to improve basic healthservices at national and local levels; and to in-tensify scientific research and apply its resultsmore fully and effectively to the prevention andcure of illness.

The importance of these goals is explicitlydefined in the Charter when it lays it downthat national development plans should in-corporate the self-help efforts of the coun-tries directed toward improvement of hu-man resources and widening of opportunitiesby raising general standards of educationand health.

Resolution A.2 annexed to the Charterrecommended to the signatory Governmentscertain long-range measures for the preven-tion of disease and the protection and re-covery of health. For the preparation andexecution of these plans, it recommendedthat the Governments utilize the technicaladvisory services of the Pan American Sani-tary Bureau and other means of technicalassistance available to them. It was ac-

knowledged that for the national planningof these and other basic activities, detailedconsideration by experts was needed, andthe Secretary General of the Organizationof American States was therefore authorizedto establish Task Forces to undertake inves-tigations and studies and prepare reportsand adopt conclusions of a general naturethat might serve as a basis for Govern-ments in preparing their national develop-ment programs.

With regard to the Task Force on Health,it was specified that it should be organizedthrough the Pan American Sanitary Bureauand that it should "appraise prevalent prob-lems and suggest general lines of action ofimmediate effect relating to the control oreradication of communicable diseases; sani-tation, particularly water supply and sew-age disposal; reduction of infant mortality,especially among the newborn; and im-provement of nutrition;" and that it also"recommend actions for education andtraining of personnel and improvement ofhealth services."

This is the great responsibility that hasbeen laid on the present Task Force, a re-sponsibility whose scope and importanceappears staggering when one considers theneeds and problems of Latin America.

NATIONAL DEVELOPMENT PLANNINGAND HEALTH PLANS

National programming of economic andsocial development is an essential prerequi-site for achieving the goals of the Alliancefor Progress. In view of the mutual relation-ship that exists between health, economicdevelopment, productive capacity, livingstandards, and well-being, the importanceand need for preparing a national healthplan is clear. The plan must establish gen-eral guidelines, in the light of an accurateappraisal of current problems and of theeconomic and administrative possibilitiesof the country. It should also set forth theobjectives to be attained in a specified time;

Organization of American States

the priorities in the solution of problems;methods of implementation and alterna-tives; specific programs and their cost; anda realistic estimation of the funds neededboth from domestic and from externalsources.

A health plan should be drawn up on thebasis of current experiences and data, andwhile the plan is being executed it should besubject to periodic evaluations in order toensure its improvement. Through this pro-cedure of planning, the problem of puttingthe available human and financial resourcesto the best possible use should be solved.

This process is a complex task that mustbe carried out through planning and evalua-tion units staffed by qualified officials. Theunits, by their very nature, should form anintegral part of ministries of public health,as is recommended in the Ten-Year Pub-lic Health Program of the Alliance forProgress.

When these health plans have been dulyprepared, they should be incorporated in thenational economic and social developmentplans. For this reason, it is obvious that theplanning units of the ministries of healthmust have appropriate representation in thenational agencies for over-all planning ofdevelopment, in order to ensure due coor-dination. It would also be advisable for suchrepresentation and cooperation to be ex-tended to all government agencies whoseactivities have a bearing on public health,such as those concerned with social security,housing, potable water supply, sewerage,rural development, and so forth.

The Organization of American States hasprovided technical assistance in the field ofdevelopment planning to almost all thecountries of Latin America, both in drawingup special projects and sectoral planningand in the formulation of over-all economicand social development plans. In providingtechnical advisory services in the field ofhealth, the OAS has had the full collabora-tion of the experts of the Pan American

Sanitary Bureau, who have cooperated withthe Joint OAS/IADB/ECLA TechnicalAssistance Missions.

NEED FOR A UNIFORM PRESENTATION

OF NATIONAL REPORTS

I should like now to mention certainpoints concerning the procedure for the peri-odic review of economic and social pro-grams, the objective of which is to ensurethat development is dynamic, progressive,and adaptable to the situation existing inthe country.

To this end the Act of Bogotá and theCharter of Punta del Este specified thateach country would present to the Inter-American Economic and Social Council(IA-ECOSOC) an annual report on thestatus of the economic and social programs,the progress achieved, the problems en-countered, and the outlook for the future.The examination of these national reportsby IA-ECOSOC will serve as a basis forevaluating the general situation of LatinAmerica and will make it possible to pre-pare suitable recommendations for intensi-fying economic and social development.

It is therefore of the utmost importancethat such annual reports be as comparableas possible, in order to facilitate their gen-eral study and evaluation. The ExecutiveSecretariat of IA-ECOSOC has thereforedecided to prepare, as it did last year, a setof standards aimed at bringing uniformityinto the form of presentation of such re-ports. Standards for presenting the publichealth aspects have been prepared by thePan American Sanitary Bureau in collabo-ration with the Executive Secretariat of IA-ECOSOC. As a matter of information, thesestandards are being submitted to the pres-ent Task Force for consideration, and it ishoped that as a result proper coordinationin the presentation will be achieved.

It might also be of interest to you toknow that the Special Committees of IA-ECOSOC, which met in Buenos Aires last

49


February and in Bogotá early this month(April), considered similar standards forthe formulation of planning projects, agri-cultural development and agrarian reform,financial and fiscal policy and administra-tion, industrial development and financingby the private sector, education, housing,and community development.

The General Secretariat of the OAS hopesthat with the cooperation of the Ministersof Health it will be possible to receive thenational reports before 15 May, so that theSpecial Committees of IA-ECOSOC mayexamine them during their second period ofsessions to be held next June. In this waythe Executive Secretariat of IA-ECOSOCwill be in a position to prepare the report.

NEED FOR TRAINED PERSONNEL

One of the most serious health problemsour countries face is the need for trainedprofessional personnel in medicine and sani-tary engineering. The seriousness of thisproblem is shown by the fact that at thepresent time ministries of health and othergovernment agencies directly concernedwith public health have approximately 2,400sanitary engineers, whereas the minimumimmediate needs are estimated at 4,050, andup to 8,000 such engineers could be used. Onthe other hand, the personnel available isnot being used to best advantage, and thesituation is further aggravated by the factthat on the average only 100 sanitary en-gineers are being graduated from LatinAmerican schools each year. It is estimatedthat during the next 20 years an average of400 sanitary engineers per year will beneeded, and that figure does not take intoaccount the current deficit.

With regard to medical personnel, thepresent number of physicians in LatinAmerica is estimated at 101,390, or an av-erage of five per 10,000 population. Whileit is true that conditions vary from countryto country and that the physician-popula-tion ratio does not in itself determine the

level of health of the people, the need toincrease this ratio is recognized, as is theneed to improve the distribution of physi-cians between the urban and the rural areas,to raise the quality of their training and ofthe technical equipment at their disposal, aswell as to increase the number of paramedi-cal personnel.

The urgent need to solve this problemmakes it imperative that our Governmentsmake every possible effort to utilize theavailable personnel to the maximum andtake all necessary steps to increase this per-sonnel, both professional and auxiliary, inthe future by enlisting the collaboration ofuniversities and other institutions of highereducation, and by utilizing the opportunitiesfor training offered by the internationalagencies. In this regard mention should bemade of the excellent work being done bythe Pan American Health Organization andthe Latin American Institute for Economicand Social Planning, under whose joint aus-pices the first course for the training ofhealth planners was begun last year. Incollaboration with the Center of Develop-ment Studies (CENDES) of the CentralUniversity of Venezuela, a guide for formu-lating national and regional health plans isbeing prepared. It would also be highlyadvisable for the Ministers of Health tomake maximum use of the opportunitiesoffered by the OAS fellowships program forthe training of professional and auxiliarypersonnel.

WATER SUPPLY AND SEWAGE DISPOSAL

The Ten-Year Public Health Program ofthe Alliance for Progress recommended tothe Governments certain projects for grad-ual development, including those to supplypotable water and sewage disposal for atleast 70 per cent of the urban populationand 50 per cent of the rural population dur-ing the present decade, as a minimum.

The Third Meeting of the Advisory Com-mittee on Environmental Sanitation, which


met in Washington in November 1961,reached the conclusion that the objectivesof the Charter of Punta del Este on watersupply in urban and rural areas could bereached if maximum efforts were made;however, it considered the objective of pro-viding sewerage systems for 70 per cent ofthe urban areas more difficult.

From that time to date, the efforts of thePan American Health Organization to ful-fill the plan for water supply and sewagedisposal services are known to all. The OASand several other international.developmentagencies have cooperated and continue toprovide technical advisory services in thatregard. Other agencies have provided finan-cial assistance to supplement the local re-sources for these activities. Outstandingamong these is the work done by the Inter-American Development Bank, which to datehas granted loans totaling more than 160million dollars for that purpose, and theseloans are being complemented locally withfunds in about the same amount. However,there is concern over the fact that most ofthe financing is being channeled toward im-proving the urban services. It is regrettablethat the rural areas have not received thesame attention.

It is to be hoped that during the presentdecade it will be possible to attain the ob-jective set forth by the Charter of Puntadel Este as regards the supply of potablewater to at least 70 per cent of the urbanpopulation. Similar efforts must be made toattain the other objective of the Charter,namely, the supply of these same servicesfor at least half of the rural population, forthey represent between 60 and 70 per centof the total population of Latin America.I am sure that, in view of these circum-stances, the ministries of health will re-double their efforts in this field. It will behighly desirable for this Meeting to embarkupon the study of the rural problem witha view to finding ways and means ofsolving it.

There is no need to insist upon the factthat health is one of the decisive factors ineconomic and social development. It is forthat reason that ministries of health mustensure the accomplishment of the sacredmission entrusted to them: to protect thehealth of the people. With that end in view,health ministries must take an active partin all those programs such as social security,housing, community development, agrarianreform, and industrial development, wheretheir assistance is essential in order to en-sure that proper attention is paid to healthat all stages of development.

Special efforts must be made to ensurethat the activities of ministries of health areduly coordinated with social security pro-grams, a goal that must be reached in mostLatin American countries. The need for thiscoordination was clearly brought out in astudy on the organization of medical serv-ices recently completed by the OAS GeneralSecretariat in collaboration with the PanAmerican Sanitary Bureau. This study,which covers five Latin American countries,shows the variety of agencies providingmedical care to different sectors of thepopulation.

In 18 countries social security programsare providing medical care to a large partof the population, and have made a substan-tial contribution toward increasing thehealth resources of the Americas; neverthe-less, in most of those countries there is noproper coordination between the ministriesof health and social security agencies, eitherin the planning or the execution stage.

It would be most advisable that the TaskForce on Health turn its attention to thissituation and make recommendations aimedat encouraging such cooperation, so that thegreatest possible return may be obtainedfrom the existing resources.

It is also necessary for health ministriesto collaborate in programs for housing andagricultural development, since these mustbe preceded by environmental sanitation

51


and provision must be made for water sup-ply, sewage disposal, and other servicesnecessary for health protection. In manyother fields, in both government activitiesand the private sector, due considerationmust be given to measures conducive to theimprovement of health conditions. In thisconnection, Resolution A.2 of the Charterof Punta del Este recommends that Gov-ernments "adopt legal and institutionalmeasures to ensure compliance with theprinciples and standards of individual andcollective medicine for the execution of pro-grams of industrialization, urbanization,housing, rural development, education, tour-ism, and others." It is in these terms thatis defined the responsibility of our Govern-ments, and particularly of our ministries ofhealth, for maintaining a constant regardfor the well-being of the individual and ofthe community, throughout the planningand execution of national development pro-grams.

ERADICATION OF INFECTIOUS

DISEASES

It is worthy of note that, to the extenttheir resources allow them, the Govern-ments of the Hemisphere have undertakensimultaneous programs to protect, promote,and restore health. There is no doubt thatone of the results of the national planningof development will be the better utilizationof resources for the solution of problemsaccording to the priority attached to them.

The large-scale systematic efforts toeradicate or control communicable diseasesmade by all countries of the Americas, withthe advice and assistance of the Pan Ameri-can Health Organization and of other inter-national organizations, are proof that a realjob is being done in the Americas. Althoughmuch has already been done in this respect,there is no question but that even more re-mains to be done. Yet it is clear that thereis complete awareness of the problem. Con-ditions will improve immensely if self-help

efforts are redoubled and the mutual aidprovided for in the Alliance for Progress isutilized.

For almost two years now, all the coun-tries in the Americas have had malariaeradication programs under way. In 1961regions with more than 5 million inhabitantshad been rid of malaria, and at present thedisease is being attacked in areas with apopulation of more than 50 million.

Rapid progress has been made in small-pox eradication, and when this campaign iscompleted there will be a smallpox problemin only two countries of the Americas.

As for tuberculosis control, the statisticaldata are relatively incomplete. However,there is no doubt that this disease is one ofthe main causes of death in some countriesof the Americas. Scientific advances nowmake it possible to attack the tuberculosisbacillus directly; and these advances, to-gether with mass vaccination campaigns,constitute the most powerful means of in-tensifying the control of this disease in allparts of the Hemisphere.

REDUCTION IN CHILD MORTALITY

In conceiving the Alliance for Progress as"a vast effort to bring a better life to all thepeoples of the Continent," the peoples andGovernments of the Americas showed thenobility of their aims and aspirations byestablishing the goal of reducing "the pres-ent mortality rate in children under fiveyears of age by one half."

All the afore-mentioned measures andmany others, all the efforts that will bemade in the social, economic, and healthfields will lead to a substantial reduction inchild mortality, which now records the lossof 1,100,000 lives every year. Yet thosemeasures, which will enhance the well-beingof the family and provide it with a morehealthful environment, better nutrition, andgreater accessibility to medical and hospitalservices, must also include an over-all cam-paign specifically aimed at combating the


causes of this awesome, excessive childdeath rate.

If we bear in mind that out of every sevenchildren born one dies before reaching theage of five, and if the aim is to reduce thishigh death rate by half, it is clear that inthe decade of the Alliance for Progress thecountries must formulate and execute plansfor solving the child mortality problem, inthe light of the national planning goals andthe available resources.

This noble task which the Americas haveundertaken will be greatly dependent onpolitical, social, economic and technologicalfactors, but in any event it must encompasssuch important aspects as improvement ofnutrition, environmental sanitation, andpreventive and curative medical care.

Children represent the future of theAmericas and embody the hopes of itspeoples. If we are endeavoring today tocreate greater well-being by satisfyingman's desire for work, home and land,school and health, within the framework ofliberty and through democratic institutions,we must complete those efforts to ensurethat the children will grow up to enjoy thatbetter life.

It should be pointed out here that withinthe Organization of American States effec-tive cooperation is being given by a special-ized agency, the Inter-American Child In-stitute. This Institute has helped, to the bestof its ability, to foster child welfare. It hasmade interesting studies and issued publica-tions on a variety of subjects, especiallyhealth, in close collaboration and coordina-tion with the Pan American SanitaryBureau.

WORK OF THE PAN AMERICAN SANITARY

BUREAU AND THE TASK FORCES

The health objective of the Charter ofPunta del Este is set forth in Title I, item8, and Resolution A.2 establishes the Ten-Year Public Health Program and the typesof measures for implementing it.

The responsibility for formulating stand-ards to establish systems of health planningin Latin America, and for providing thecountries with technical advisory services inthe preparation and execution of theirhealth plans, was laid on the Pan AmericanSanitary Bureau. The Bureau was also en-trusted with the organization of the TaskForce on Health to appraise prevalent prob-lems and suggest general lines of action ofimmediate effect.

In placing this responsibility on the PanAmerican Sanitary Bureau, the Govern-ments of the Americas have once againgiven it a well-deserved vote of confidence,which it fully merits by reason of whatit has done to promote health in LatinAmerica.

With the object of preparing studies andanalyses in depth of almost all those healthactivities that should find a place in na-tional plans, the Pan American SanitaryBureau has convened several AdvisoryGroups of experts who have produced aseries of important reports on environmen-tal sanitation, nutrition, medical education,health planning, medical care, health sta-tistics, and medical research.

In this hour of pressing needs, we mustboldly face new situations and the problemsthey present. We must urgently initiate thechanges necessary to adapt national struc-tures to the time we are living in. It hasbeen said that the twentieth century will bedefined as that stage in civilization whenthe concern to conquer underdevelopmentwas aroused. It is the century in which agigantic effort is being made, deliberatelyand with the aid of revolutionary techno-logical means, to eliminate poverty andcombat disease. Of all the resources avail-able for economic, political, and social de-velopment the most important is man. Heis the protagonist as well as the beneficiaryof all development. Human potential is thusthe basis of all our aspirations for progress.

53


To carry out health programs is to protectthis human potential. On this solid basis wecan work for both moral improvement andthe preservation of spiritual values.

For that reason, Gentlemen, the conclu-

sions reached by this Task Force and theway in which our Governments make use ofthem will be of decisive influence in thestruggle to achieve happiness for America,a struggle which unites us all.

MESSAGE OF WELCOME FROM THE PRESIDENTOF THE UNITED STATES OF AMERICA*

Presented byDR. LUTHER L. TERRY

Surgeon General, Public Health Serviceof the United States of America

I am happy to have this opportunity tospeak to you briefly and to welcome themembers of the Task Force and all theparticipants at the Meeting.

It is gratifying to learn that at leastfourteen of the Ministers of Health andmost of the key health personnel from theAmericas are meeting here to discuss thismost important subject.

It gives me particular pleasure to an-nounce to you that President Kennedy hasindicated that he expects to meet with thegroup later in the week, but in the meantimehas sent a personal message which he wouldlike me to deliver to you. His message isas follows:

"I warmly welcome the Ministers ofHealth of the American Republics nowmeeting with you in Washington. As theleading health officials of this Hemisphere,you are met in a significant cause to planthe programs which will give full meaning

* Presented at the first plenary session, 15 April1963.

to the words and ideals of the Charter ofPunta del Este.

"The Ten-Year Public Health Programof the Alliance for Progress, which appearsas Resolution A.2 of the Charter, is a state-ment of principles to which the Governmentof the United States wholeheartedly sub-scribes.

"The 'Charter contains objectives whichare quite specific and no less important tothe future health of our peoples than thecurrent campaigns under the Pan AmericanHealth Organization against malaria andsmallpox. It envisions an increase of fiveyears in the life expectancy at birth of everyperson within the present decade, and itcalls for a 50-per-cent reduction in thepresent mortality rate of children under fiveyears of age. The Hemisphere looks to youto specify the means by which these ob-jectives may be reached.

"We in the United States have alreadypledged our interest and resources. We relyon you, as experts in this field, to point theway."

55

ADDRESS BY THE PRESIDENT OF THE INTER-AMERICANDEVELOPMENT BANK

MR. FELIPE HERRERA


I bring to you most cordial greetings fromthe Inter-American Development Bank, itsBoard of Governors, and its officials. Duringthe past two years all of us have had thegood fortune to be closely associated withmany of you present in this room, where Isee so many friendly faces. Our most cordialgreetings to all of you.

I also want to express particular appre-ciation for the kind invitation extended tome by the Director of the Pan AmericanSanitary Bureau to be with you at thisMeeting. This specialized conference is per-haps the most important event in the publichealth sphere since the Punta del EsteMeeting in August 1961, for we are con-vinced that improvement in health condi-tions is an essential prerequisite to economicgrowth. We have especially welcomed thisopportunity to explain to you how the Inter-American Development Bank has come tobe connected with the matters that concernyou, and for our part, to learn, through thework that you will do in the course of thisweek, of your special problems and points ofview, since these will have a basic influenceon the Bank's future policy in this field.

Before turning to the specific work of theInter-American Development Bank, I wantto make special mention of the preparatorywork done by the Pan American SanitaryBureau. I recall that even before the Agree-ment Establishing the Bank was signed,early in 1959, Dr. Abraham Horwitz workedassiduously with the delegates from thecountries negotiating the Agreement to con-

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vince them that the new financing agencywould play a limited role if it could notattend to the health needs of the Hemi-sphere. He believed that the new financingagency should be free to act in conjunetionwith other organizations which had ma-terially aided economic development, butwhich had not been in a position to co-operate with our communities to achievehigher health levels.

I believe that it was due to Dr. Horwitz'sconcern, a concern voiced for decades by theBureau, that a flexible and constructiveoperating formula was established for theBank. Besides our basic capital resources,the Fund for Special Operations was es-tablished by means of an additional$150,000,000. This was done to permit theinstitution, when it announced its disburse-ments in February 1961, to meet certain re-quests that bankers would not considerstrictly orthodox and recoverable financing.

Later there was a new development whichperhaps not even Dr. Horwitz and his as-sociates could have foreseen. The eightofficials responsible for examining the firstrequests for loans agreed to apply to thefinancing of loans for water and seweragesystems the same criteria that they applyto the financing of loans for electric powersupply, development of transport systems,or improvement of national industrial ca-pacity. So, with the cooperation of yourtechnical experts, the Bank was able totransform many applications from yourcountries for improvement of their water

Inter-American Development Bank

supply systems into financially feasibleprojects. One must realize that to take careof such requests, we could use our ordinarycapital only to meet the needs of the largestcities or those communities where a satis-factory organization and water-rate systemcould be established and the improvedpublic service administered on a strictlybusiness basis.

Let us recall that the Bureau, as well asthe Bank, attributed special importance toour first operation, a loan to improve waterservice-both potable and industrial-inthe city of Arequipa in southern Peru. Thiswas not only our first health undertaking,but also our first banking undertaking. It isinteresting to note that for this operation-in spite of the prophesies of the ever-presentsceptics-we obtained the support of U.S.commercial banks. So we could prove thatthe financing of projects of this sort may benot only a possible object of interest to adevelopment bank, but under certain con-ditions may arouse the interest of the com-mercial bank. However, we should havebeen very limited in our sphere of actionhad we not held the historical meeting atBogotá.

The Act of Bogotá established, in Septem-ber 1960, the basis of what is today theSocial Progress Trust Fund. You will recallthat the generous decision of the Govern-ment of the United States of America toplace 500 million dollars at the disposal ofthe inter-American system had a far-reach-ing effect, as Dr. Mora has just pointed outin his interesting and constructive remarks,when he noted that there is no economicdevelopment without social development.This statement, which seems very obviousto us today, received very tardy acceptancein all our countries, especially in the fieldof inter-American relations.

It was only in September 1960 in Bogotáthat our countries agreed that every efforttoward economic development aimed at di-rect improvement in production would in-

evitably be limited if it were not accom-panied by a parallel effort to improve socialconditions and link these two aspects ofdevelopment which, in practice, are but one.

However, as bankers, we are well awareof the fact that, from the purely financialand technical point of view, we cannot treatthe two aspects as one unless we take cog-nizance of the origin of each, for it is ob-vious that the financing of social projectscalls for much more flexible terms as regardsrepayment periods, interest rates, and typeof currency acceptable for repayment.

As for development procedures, all of usknow that our financial agencies unfortu-nately possess limited resources and have nomeans of increasing these other than by re-sorting to the private capital market, wherethe interest rates are such that it is not easyfor our agencies to channel the funds ob-tained into the financing of social needs.

That is why the contribution to thisSocial Fund of 500 million dollars bythe Government of the United States ofAmerica, from public funds and at the ex-pense of the taxpayers, is of such far-reaching significance.

The Bank became the principal adminis-trator of the Social Progress Trust Fund.We had practically 80 per cent of these re-sources at our disposal, to be used in fourbasic fields: first, rural development; sec-ond, housing; third, sanitation works, es-pecially potable water systems and seweragesystems; and finally, education.

As Dr. Mora also pointed out, the fore-going situation has made it possible for theBank, after little more than two years ofoperation, to finance out of its own resourcesand the funds which it administers, morethan 160 million dollars worth of projects.This outlay created, in turn, expendituresof similar amounts from the domestic re-sources of the countries concerned. In prac-tice, then, our action-I venture to say ourcatalytic action-has precipitated the in-vestment of more than 300 million dollars

57


in Latin America for water supply andsewage disposal systems, and other sanita-tion works.

What I have said does not mean that weare completely satisfied with the work done.We know that we still have much to do. Weknow that from now on we must improveinternal and technical administration of theBank in order to adapt it to the needs of thecountries. We know that we must maintainan even closer contact with you, with theministries in the different countries, with thespecialized agencies. But we are sure of onething: that the great Latin American dedi-cation of our personnel, joined with yourenthusiasm for serving your communities,will enable us to put into prompt operationprograms that Latin America has never be-fore known. I can say, without fear of ex-aggeration, that this is the first major en-deavor in the field of international relationsin which the countries have become as-sociated with international financing or-ganizations and technical agencies in orderto assist the national effort of their respec-tive Governments.

It is worth emphasizing that the Bank hascarried out important operations and is nowconcerned with taking care of projects forfinancing water supply and sewerage sys-tems. Someone remarked to me that perhapsthe Bank is becoming too liquid; this neednot disturb a banker, of course. This ex-pression reminds me also that a few monthsago in a small community in Guatemalacalled San Lucas de Sacatepéquez, on theoccasion of opening the waterworks in thepresence of 600 or 700 people of the com-munity, the mayor said, in the course of awitty speech thanking us for our work:"Sir, we thank the Inter-American HealthBank for its interest in us." It is fortunatethat Dr. Horwitz was not there, for hemight have thought that our agency wastrying to take all the credit.

.By December 1962 we had financed 933water supply and sewerage systems, which

benefited 15 million people in 855 smallcommunities. By the same date we hadhelped to create new national or regionalagencies which took charge of these activi-ties, and we had worked with the Govern-ments in reorganizing seven similar agen-cies.

The Bank has devoted an important partof its resources to this work, committingthem to long-range plans. It would be idleto think that we could continue to do this,as bankers, unless more funds are placed atour disposal for meeting the needs of thecountries. That is the reason why the Bankis now working actively to increase its ownresources. A few days ago our Board ofGovernors approved an increase in the capi-tal of the Bank that would practicallydouble its resources.

We hope that between now and the endof the year the various Congresses will haveratified this change in the Agreement Es-tablishing the Bank, which will be of bene-fit to all our countries. I also think it ap-propriate to recall that only a few daysago the President of the United States ofAmerica proposed to the Congress of thatcountry new forms of foreign aid for thefiscal year 1964, and pointed out the advis-ability of increasing the Social ProgressTrust Fund by another 200 million dollars,suggesting that this sum also be put underthe administration of the Inter-AmericanDevelopment Bank.

I believe that in this way the Bank willbe in a position to continue drawing upprojects in agreement with the countries andwithin a few months will be able to makenew commitments for loans.

All of you know that a request for fundsfor foreign aid by the Chief Executive ofthe United States to Congress is one thing,and the final decision is another-as is thecase in the constitutional machinery of ourown countries. However, we have reason tohope that this proposal to increase our re-sources will not meet with objections and

Inter-American Development Bank

will enable us to take care of the needs ofsome countries.

Since we are speaking of new funds forforeign aid, I deem it a duty, since I shareyour interest and your objectives, to tell youof the difficulties that we face just now. Incontacts made with our respective countries,whether on trips or in the course of con-versations with authorities or with business-men, we have often found misunderstand-ings about the character of aid from abroad.There is a belief that there is some sort ofopen bank account on which countries maydraw freely. What is not always understoodis that, unfortunately, a negative sort ofattitude toward foreign aid is arising in themore developed countries. Influential groupsare asking, for example, what sense it makesfor the more advanced countries to continuegiving financial aid to less advanced coun-tries for economic and social development.

Happily, these voices are in the minority,and happily too, the leaders of the westernworld understand that the new countriesneed strong support in this decade of de-velopment. It is evident that without thisaid they will not perish, but it is also ob-vious that conditions dangerous to theircollective life may be accentuated and thatwithout help from abroad it will be muchharder for them to strengthen their demo-cratic institutions.

We believe that aid for development willcontinue, but it must go hand-in-hand withinternal effort. I think that in this connec-tion a splendid step has been taken inthe formulation of national developmentplans, especially the new technical approachwhereby the plans contain special chaptersdevoted to public health, which shouldreceive priority.

It is interesting to see that the committeeof nine experts, in reviewing the programsalready submitted to it, has in the case ofmost programs, whether of short or longrange, given public health the priority whichit deserves. I believe that this fact is im-

portant, for it gives some clue to the amountof foreign funds that we may possibly haveat our disposal. It is even more importantto you because these programs are going toaid your work and that of specialized agen-cies, inasmuch as they represent a promiseof the Governments to allocate annually, inbudgets or through their agencies, sufficientinternal resources, without which thesecollective programs cannot advance.

Before closing, Gentlemen, I also want torefer to other tasks undertaken by the Bankin cooperation with the Pan American Sani-tary Bureau. I shall mention especially ourmutual desire that the specific water andsewerage programs be integrated with thebroader programs of urban and ruralsanitation.

Dr. Mora has rightly noted that one ofthe limitations of the inter-American actionin this field is the delay, to a certain degree,of work in rural areas. I daresay this post-ponement is not peculiar to the field of pub-lic health; by virtue of being widespread, itconstitutes one of the tragedies of LatinAmerica. Even though we are a typicallyrural continent, our econonice and financialpolicy has been directed for the most partat the most important urban centers. Youare well aware that before now, when any-one discussed plans for water and seweragesystems, he had only the large cities inmind. But fortunately, thanks to the size-able effort of the officials of the Bureau, agrowing trend in favor of rural communitiesis noticeable, and is increasingly reflected inthe requests for technical advice and fi-nancial aid received by the Bank.

Among matters relating to the rural en-vironment, I must also mention our tech-nical participation in veterinary health pro-grams designed to better the general healthof the population. The Inter-American De-velopment Bank has financed numerouslivestock programs in Latin America, butin many places it has encountered a situa-tion that you are familiar with: the pres-

59


ence of livestock diseases and other dis-abling biological factors which create seri-ous obstacles to meat and milk production.Consequently, we are trying to develop, incooperation with the Pan American Sani-tary Bureau and the countries, an inte-grated type of program which will make itpossible to derive the most effective resultsfrom the livestock programs.

Officials of the Inter-American Develop-ment Bank look upon the Pan AmericanSanitary Bureau as a sister organization.We have reaped great benefits from workingtogether during these three years. That iswhy we do not fear Latin America's popu-lation explosion. When we are told that bythe year 2000 there will be 600 million peo-ple in Latin America, we regard this de-velopment as a really great dynamic forcefor the Hemisphere, not as a deterrent fac-tor, for we are sure that the populationexplosion in Latin America has a totallydifferent meaning and connotation fromthat which it has in other already over-

populated regions. After studying the con-ditions of underdevelopment in our coun-tries, we believe that by means of our workand our natural resources, the Hemispherecan sustain a population greatly in excess ofthe present one. What is more, we thinkthat it is this very increase in populationand the resulting great markets which aregoing to give Latin America a decisive posi-tion in international affairs. But in theInter-American Development Bank we alsorealize that a numerical estimate has littlemeaning. Six hundred million Latin Ameri-cans will be of little avail if a large pro-portion of them are illiterate or sick. Thencesprings our aspiration to build a firmereconomic foundation for the future-it isyour aspiration, too-in order that the fu-ture population may be happier, better edu-cated, healthier, a population that feels it-self continuously participating in and linkedto the collective endeavor and the strength-ening of the most precious values.

ADDRESS BY THE SECRETARY OF HEALTH AND WELFARE OF MEXICO,ON BEHALF OF THE MINISTERS

DR. JOSE ALVAREZ AMEZQUITA


We live in a time of rebellion. In pasttimes man accepted scarcities and evils asfruits of an irremediable fate, inherent fea-tures of human existence. Today he rebelsagainst these scarcities and ills; he tirelesslyseeks ways to conquer them and wipe themout.

America, this Hemisphere that a greatEuropean thinker called the land of the fu-ture, could not remain apart from thisbattle; it united in the Alliance for Progress,a union of ideals to better the lot of theAmerican peoples. The Alliance for Prog-ress faces crucial economic problems; and itwould be impossible to accomplish its aimsif those problems were not solved. The Alli-ance means that improvement in the lot ofour peoples will convert them into both pro-ducers and consumers, and that great mar-kets will stimulate the industrial growth ofareas now submerged in economic underde-velopment. It seeks the well-being of manand the community.

All the countries of the Americas wantand need to better their living conditions,to raise the levels of cooperation, which arenow high and in some respects exemplary,while in others they leave something to bedesired and could be considerably improved.But our ideals and desires would be of noavail if we did not translate them into action-just, human, sincere action. Above ab-stract ideas, statistics, and scientific studieslooms the sad reality that the majority ofthe Latin American peoples are sunk inpoverty, ignorance, and ill health. These are

all common problems in this part of theHemisphere. It is not merely a theoreticalquestion, a matter for cold analysis andarithmetical calculations. We deal with hu-man tragedy of immeasurable scope, withan outrageous misery that oppresses ourpeoples.

I think that we in the public health ranksmust take priority, for it is we who bestunderstand these truly human aspects of theAlliance for Progress. The Charter of Puntadel Este looks upon public health as one ofthe principal factors in the accomplishmentof its goals. But this factor has not beenrightly weighed by some economists whomerely manage figures and abstract ideas.The scope of our task and the intensity ofour effort really come from contact with thepeople, a sincere approach to their prob-lems, and an understanding of the humandrama of every individual.

And this effort should be, must be, of mul-tiple origin. From now on we must devoteall our ability to the pressing task of draw-ing up realistic programs of immediate ap-plication which will bring health to our mostbackward rural areas and to the belts ofpoverty that surround our cities, so thatthere will no longer be disinherited men inAmerica, but men capable of exercising lib-erty with dignity.

But this will not be enough. We must seeto it that the economists and politiciansdraw near the people, not only through cur-tains of figures and statistics which chill andmechanize everything, but across the thresh-

61


old of sincere solidarity, man to man, Ameri-can to American, which is the finest idealof the Alliance for Progress. From this pointof view, and as servants of the humble manof our Americas, not as politicians, we mustappraise all the efforts made, no matterwhere or how they are made. Other coun-tries have drawn near the individual manand are already reaping the fruit of theirwork. We do not deny it.

For us, the war is against poverty, ignor-ance, and ill health within the framework ofdemocracy. We therefore proclaim that ourfight is of an essentially peaceful character,for it is not directed against man but to hissupreme advantage. Allow me here to recallthe struggle of President Adolfo López Ma-teos for peace, the indispensable base ofprogress, in the absence of which we shouldnot be meeting here in our common desirefor the betterment of man. President LópezMateos brought to the world his messageof peaceful coexistence, founded on the tra-ditions of mutual respect and social justiceof the Mexican Revolution. Social justice,because there will be no peace so long asdeep gulfs exist between peoples, so long asthere are rich peoples and poor peoples.

These humanistic ideals of the MexicanRevolution-we say it with pride-in greatmeasure give shape to the Alliance for Prog-ress. We were the first in America to bringabout a social revolution, and we are happythat now the entire Continent will followthis road. The distinguished President of

the United States of America, John F. Ken-nedy, creator of the Alliance for Progress,shared this conviction. He expressed it dur-ing his visit to Mexico, when he said thatour country is enjoying the benefits of ourRevolution and that the North Americanpeople are also the offsprings of a revolu-tion. The Alliance for Progress is a con-structive social revolution which, whenrealized, will plot a new course for theAmerican Hemisphere.

Therefore, we dedicate all our enthusi-asm, all our effort, to achieving the idealsof the Alliance for Progress. We know thatall the Latin American countries are eagerto push on in a true, sincere, honest jointeffort which will lead to the total bettermentof the American peoples. Our resources arelimited, but this fact should not stand in theway. It is vital to begin basic programs ofhealth, sanitation, water supply, housingimprovement, nutrition, etc., however lim-ited their range may be. The importantthing is that there should be practical plans,easy to develop, which will contribute to thegeneral welfare, and that we should not sitidly waiting for the achievemnent of largeprograms which call for resources now be-yond our scope.

We are sure that this is the right road, theroad of sincere and immediate cooperation.We have faith in America, in our destiny,and in liberty. And for that reason we putour trust in our own possibilities to achievea brilliant future.

STATEMENT ON THE ORGANIZATION AND DEVELOPMENTOF THE MEETING *

DR. ABRAHAM HORWITZ

Director of the Pan American Sanitary Bureau, Regional Office of theWorld Health Organization for the Americas

Resolution A.4 of the Charter of Puntadel Este specifically entrusted the PanAmerican Sanitary Bureau with the organ-ization of the Task Force on Health, as theSecretary General of the Organization ofAmerican States pointed out this morningat the first plenary session.

The resolution gives the Task Force thespecific responsibility for analyzing thehealth provisions of the Charter of Puntadel Este and for indicating what, in itsopinion, are the practical means of reach-ing the health objectives of the Charter. Itis, then, a matter of planning, for both theimmediate and the more distant future, howthe progress already made in Latin Americain the field of health may be continued.Those who represent the highest authorityfor solution of the health problems of theHemisphere-that is, the Ministers andtheir senior advisers-must assume respon-sibility of this sort within the general proc-ess of development now under way. Theiropinions, transmitted to the Organizationof American States, will be of the greatestpossible aid in advancing public healththroughout the Hemisphere to the state ofexcellence necessary to all social progressand economic growth. It was for this reasonthat I had the honor of inviting the Minis-ters to the present Meeting. The diversityof health problems covered in the Charterof Punta del Este was taken into account,as was the necessity of preparing basic

* Presented at the second plenary session,15 April 1963.

documents to clarify them. The need fordrawing up authoritative recommendationsand suggestions that would permit the Min-isters to make an exhaustive analysis of theproblems was also borne in mind. Thanks tothe generous contribution of the Organiza-tion of American States, it was possible dur-ing the past year to organize Advisory Com-mittees on health planning, medical care,medical education, research, sanitation, ma-laria, nutrition, and statistics. The conclu-sions they reached were sent to the Minis-ters together with other studies preparedby technical experts of the Pan AmericanSanitary Bureau. They represent the opin-ion of more than 100 experts from the Hemi-sphere, some of whom are present at thisMeeting. They reflect the views now currentin the Americas on the solution of everybasic health problem mentioned in theCharter of Punta del Este.

As I have stated previously, we believethat these studies will be a valuable basisfor your discussions. It is well to keep inmind, Mr. President, that the Governmentshave approved the Charter of Punta delEste and the Ten-Year Public Health Pro-gram it embodies. So it is now a questionof how to implement it, what the practicalmeasures are that each Government cancarry out, short-range and long-range. Thereis no doubt that we are witnessing a newchange in the concept of health, which itwill be worth while to state once more, be-cause your voice, Gentlemen, is the onewhich will ring out in the Hemisphere with

63


the greatest resonance in all spheres of ac-tion. That concept holds that health is anindispensable component of development.It calls attention to the influence of healthon economic growth. It again points outthat, besides being a good thing, perhaps themost precious of good things, health is alsoa mechanism essential to the furtheranceof the economy and its progressive growth.It shows to those who do not wish to viewthe problem from a purely spiritual stand-point that health also contributes to eco-nomic advancement-on the one hand be-cause it allows people to find and developnew sources of wealth, and on the other,because in the absence of healthy men therecan be neither economic growth nor tech-nical progress.

Therefore, with all due respect, Mr. Presi-dent, I should like to propose that in theFinal Report of this Task Force reaffirma-tion be made of a concept which perhaps isnot new, but which at this time has acquiredparticular significance.

The outstanding health problems in theAmericas and the criteria to be used in es-tablishing priorities in each country shouldalso be defined, as the Charter of Punta delEste points out. Our societies are different;our environments are diverse; their influ-ence on our inhabitants is likewise different;therefore, our problems vary in nature andextent. The statements of the Ministersduring the plenary sessions will aid in work-ing out this aspect of the Final Report: thebasic health problems of the Hemisphereand the criteria for establishing priorities.The Charter also states that the Ministers,as I have mentioned, rnust indicate whatmeasures should be adopted to reach thehealth goals. To this end, we considered itexpedient to propose two committees. Thefirst will devote itself to an analysis of theprevailing problems mentioned in the Char-ter, as well as such other matters as theMinisters consider worthy of consideration.This committee will have the task of dis-

cussing the problem of disease and its char-acteristics; its most prevalent aspects inthe Americas; the problem of nutrition; theproblem of sanitation; it will also be calledupon to examine the basic health objectiveof the Charter-an increase in life expect-ancy at birth by an average of five yearsper person during the decade. The secondcommittee will have the task of analyzingthe basic means that public health employsto attack and solve its specific problems.Therefore, we include among the topics forthis committee the planning, organization,and administration of public health services,education and training, and research. Ineach of these committees the Ministers willbe able to analyze the more pertinent as-pects of the prevailing problems.

We think that the opinion of the expertsof the Hemisphere, which met in the courseof last year at the Pan American SanitaryBureau, can be of significance for scrutiniz-ing these problems in the committees. Thecommittees should propose recommenda-tions of a practical nature for each problem;these should be considered in plenary ses-sion for their inclusion in the Final Report.They will present the measures which shouldbe adopted in order to reach the health ob-jectives of the Charter of Punta del Este;these will be both general and specific meas-ures. The summary of the discussions willbe embodied in the Final Report, for thepreparation of which the President has seenfit to appoint a Drafting Committee; thetext of the Report will be approved inplenary session.

This Report, as the Charter of Punta delEste stipulates, will be sent through thePan American Sanitary Bureau to theSecretary General of the Organization ofAmerican States.

This, Mr. President, is how we have con-ceived of the work of this distinguishedTask Force and the manner in which itswork is to be carried out. All that I have

Pan American Sanitary Bureau

proposed is only a respectful suggestion.The Task Force has full authority to carryout its work in the way that it deems mostadvisable. But the Bureau believes that ifthis method is followed a very arduous mis-sion can be completed in a very short time.We cannot forget the historic import of thepresent Meeting. Perhaps since December1902, when the International Sanitary Con-vention gave birth to the Pan AmericanSanitary Bureau, there has not been an-other occasion in the Americas when thehighest health authorities have assembledto discuss exclusively technical affairs ofsuch importance and influence, at a time sounique as that which the Hemisphere is nowwitnessing. Perhaps at no other time in thiscentury has the significance of man, as thesynthesis of all the efforts of a society, been

more remarkably demonstrated. In thetwentieth century there has been no otheropportunity for those who have the moraland intellectual authority to do so, to em-phasize the humanitarian purpose of everyeconomic system, whatever the political re-gime to which they are subject. Nor hasthere been, either in America or in thiscentury, another opportunity for giving ex-pression to a sense of national purpose byrecognizing health as a fundamental com-ponent of social progress and economicdevelopment.

Mr. President, we of the Pan AmericanSanitary Bureau have tried to fulfill ourduty in the best possible manner. In offer-ing the fruit of our efforts, we wish to statethat we are at the service of the Task Forceand of all the participants in the Meeting.

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ADDRESS BY THE MINISTER OF SOCIAL WELFARE, LABOR,AND HEALTH OF ECUADOR

DR. LUIS PALLARES

Presented at the Second Plenary Session15 April 1963

In the course of this important confer-ence, I am sure that repeated emphasis willbe placed on the basic theme that the devel-opment of peoples is contingent upon thedevelopment of public health, for it is im-possible to conceive of material and eco-nomic progress of a nation or a State if itis not based on higher levels of health.

In the Americas we have pathetic caseswhich prove this assertion and which, byhighlighting this concept, enable us to de-duce the standards and principles we mustpursue in search of better conditions of lifeand, ultimately, a better future for ourpeoples.

Let us call to mind the importance, forthe destiny of America, of the eradication ofyellow fever in Panama and the Canal Zone.By virtue of its special geographic situation,that area then constituted one of the keysto the economic and social development ofthe countries located on its flanks.

Besides the shining example in that area,I can also mention a similar case in my owncountry. Some years ago, when Ecuador hadnot succeeded in eradicating yellow feverand plague from its territory, its economicand social development w as at a virtualstandstill because the level of public healthwas so low.

These experiences show that the organiza-tion and development of health campaignsfor the elimination of the principal com-municable diseases bring about, as a logicalconsequence, the concomitant organizationand development of the countries that carry

them out. By increasing production theyclear the way for progress and, with it, forhigher aspirations in every sphere of life'sactivities. Even today we are witnessing un-paralleled situations; regions formerly un-healthy because of malaria are being pro-gressively incorporated into the economiclife of countries and settled at an acceleratedpace.

Such past experiences have, in turn,spurred the American countries on to makeall the necessary efforts to draw up andestablish public health plans in consonancewith the means available to put them intoeffect, in order that States and their Gov-ernments may devote their best endeavorsto the preservation of human capital. Thisis because they are sure that only if theycarry out the programs planned can theyreach the goals that they have set for them-selves, thereby promoting the formation ofa population ready for harmonious andwell-planned economic and social develop-ment.

And the conviction that the united effortof the Latin American Republics in this fieldwould give the best result in achieving defi-nite aims and better public health goals, ledthem to join together under the Alliance forProgress and to establish those goals in theCharter of Punta del Este. We are here to-day in that connection, for the purpose ofdiscussing and fixing the most suitable andexpedient avenues to pursue and the mostadvisable and practical methods to employ.

But allow me to say that, in my judgment,

66

Ecuador 67

the policy of subordinating the developmentof health plans to the execution of agrarianand tax reforms in the countries of theHemisphere has serious disadvantages, sincethese reforms, by their very nature, must becarried out at a pace that is not comparablewith the urgency that the health plans callfor. Thus, while I believe it essential thatthe Alliance for Progress emphasize theneed to bring about these reforms, it mustin turn, and in a parallel, though not com-plementary manner, establish and executehealth plans for the American countries thatcannot wait for the necessarily slow evolu-tion of those other reforms.

In light of these considerations, the Gov-ernment of my country, through the Na-tional Planning and Economic CoordinationBoard, is now drawing up a National PublicHealth Plan, as a part of the general planof economic and social development whichaspires to achieve the goals of the Charterof Punta del Este. It will also set up aHealth Planning and Evaluation Office toappraise the results of this Plan as it is putinto practice.

The formulation and execution of thePlan will reinforce and invigorate our healthinstitutions, and will encourage the mostprompt pursuit and completion of the pro-grams now under way. Among these, theeradication of certain communicable dis-eases such as malaria and smallpox, whichin the past have lowered human potential,takes preference. In Ecuador, as in otherRepublics of the Hemisphere, these cam-paigns are well advanced, and their resultsare easy to verify in terms of collectivebenefit.

In Latin America we are witnesses to thedramatic spectacle of high morbidity andmortality in children, which reduce to in-conceivable figures the life expectancy ofits inhabitants, especially that of children-morbidity and mortality resulting fromenvironmental conditions, since the princi-pal causes are gastroenteritis and other in-

fections of the digestive tract. It is essentialto eliminate these basic causes, insofar aspossible, by promptly implementing pro-grams of water supply, sewerage, excretaand garbage disposal, and programs to im-prove other environmental factors that havea direct influence on the life and develop-ment of the human being.

In Ecuador, as in all the countries ofAmerica, the provision of water supplies andof sewerage and excreta disposal systemscalls for great financial outlays, which areundoubtedly beyond the present state orfiscal capacities. It is enough to cite thefact that, if my country is to achieve thegoals of providing water and sewerage for70 per cent of the urban and 50 per cent ofthe rural population by 1971, it will benecessary to invest not less than $300,000,-000, which will require an appreciable in-crease in the resources now available forthese purposes, to be obtained perhaps bya marked increase in the percentage whichthe national budget now allocates to healthcare.

The effort is enormous, but it must bemade. I have no doubt that the other coun-tries of the Americas will have to do thesame. Henceforward they will have to as-sign those higher percentages to health,when it is necessary, just as they are nowassigning them to education, national de-fense, etc. Otherwise, in the matter of health,they will not be able to create the financialconditions necessary to ensure that theirown efforts are supplemented by externalaid.

What I have said does not mean that,in order to lower the frightful infant mor-tality rates, we must depend exclusively onthe benefits furnished, in middle or long run,by environmental sanitation. We must makea realistic appraisal of the true needs of ourchildren for medical care and exhaust allefforts to satisfy them, since it is not prac-ticable to speak of reducing child mortality


when medical services are incapable of satis-fying the needs of children.

We know full well that in our countriesmany children die because of the inade-quacy, especially in quantity, of medicalcare. Consequently, we must realize that inthis kind of work the closest cooperationamong public and private institutions de-voted to the same purpose is indispensable.

Let us make the Governments and thepeoples aware, then, that each of our coun-tries must devote its best efforts and allo-cate greater financial resources to the pro-tection of public health.

We must also focus our attention on theundeniable fact that the execution of healthprograms in America will call for real andeffective aid from external sources of fi-nance. In this respect, I want to stress theindisputable fact that, in order to be suc-cessful, the Alliance for Progress must allotto the nations of America, in this field morethan in any other perhaps, the greatest tech-nical assistance and the consequent financialaid, which from now on must lead to theaccelerated fulfillment of these public healthplans and programs. It must endow theinstitutions charged with providing the as-sistance with such flexibility and efficiencyas give unmistakable assurance that theresources of each country will be rapidlyrounded out with this external aid, sincethe goals of the Charter of Punta del Estecan be achieved in no other manner.

Technical knowledge has made greatheadway and banished empiricism frompublic health affairs. It must be so in-creased in Latin America that, with it as afoundation, feasible plans and programs ofimmediate effect can be carried out. Thecountries of the Hemisphere definitely needa greater assistance from international or-ganizations in order to increase rapidly thehuman resources that are to speed up theprograms of environmental sanitation, thoseof preventive and curative medicine in gen-

eral, and all other kinds of programs which,in the essential field of health, are to as-sure a better life to the population of theAmericas.

Thus, if this is the real issue that facesLatin America today, our fundamental taskshould be to aim primarily at bettering en-vironmental conditions, giving the highestpriority, in any ten-year public health plan,to the programs I have just mentioned.Naturally, we must not forget that the crea-tion of demand for these benefits and theiruse by the people, will depend on an essen-tial concomitant task, namely, that ofhealth education to be carried out from thefirst years of school. Only by requiring theinclusion of minimum instruction in healtheducation in the general curriculum, byfamiliarizing children and adults with therequisite habits of hygiene and publichealth, can we assure the success of suchprograms. This instruction should never besporadic or weak, but should be the con-stant hammering away that makes forawareness in the child and which, like lan-guage or other learning, becomes a part ofhis very life, so that the number of peopleinfluenced by this kind of teaching and theseprinciples may constantly increase.

Finally, we must note that the peopleswho conquer health problems not only gainthe intrinsic benefits derived from health,but also acquire political stability, which inour Hemisphere is a basic ingredient forcontinuing progress.

The peoples of America rightfully de-mand better opportunities for leading a use-ful and productive life, which must be basedon better health conditions, on better edu-cational opportunities, and on better hous-ing conditions, which must raise human dig-nity, bestow peace as well as justice, andmake for a Hemisphere of equal aspirationsand equal rights, a Hemisphere with fullfaith in democracy.

ADDRESS BY THE MINISTER OF SOCIAL WELFARE ANDPUBLIC HEALTH OF ARGENTINA

DR. TIBURCIO PADILLA


The Delegation of Argentina accepted theinvitation to participate in this type of dis-cussion because from the outset we havebeen inspired by and identified with theaims of the Charter of Punta del Este, whichsupposes a common effort on the part of allthe peoples of Latin America to improvehealth, living, and economic conditions.

In our country this need is even moreurgent than in others. Two dangers threatenus: totalitarianism from the right, which in-jured our country for 12 years, and totali-tarianism from the left, with which all ofyou are acquainted. The precarious situa-tion of the Argentine worker means that heis fertile ground for doctrines which I prefernot to pass upon.

Because of all this, I believe it necessaryto aid our population as soon as possible,with the Alliance for Progress.

As for specific public health motives, thegrowth of our population and culture hasresulted in a greater need of our people formedical services. Therefore, it is imperativeto take advantage of the present advancesin technical procedures in the health fieldand to apply them with efficiency.

It is also essential to create an awarenessin the private practitioner, whose collabora-tion is indispensable. Up until now, in ourcountry the clinician looked down a bit onthe public health physician. Now all this ischanging.

We consider the cooperation of the privatepractitioner indispensable, for the reasonthat the State alone does not have sufficient

resources to achieve health education. More-over, because of the high cost of all thesemodern procedures, planning is essential.Therefore, the suggestions of the Pan Ameri-can Sanitary Bureau were very well re-ceived, and we have embarked on planning.But it is not enough to draw up plans; it isnecessary to have the means to implementthem, and when I say "means" I do notrefer to financial means alone, but also topersonnel.

Consequently, we are devoting ourselvesenthusiastically to the training of healthpersonnel. In formulating our plans, werealized that the Ministry of Public Healthcould not do all this alone, so we enlistedthe collaboration of other Ministries-Edu-cation, Public Works, Housing, Industry,and Agriculture-because sometimes it iseasier to build a new road than a new hos-pital. We have taken all these factors intoconsideration in order to obtain greaterefficiency.

What has the Ministry done about plan-ning? For the short-range plan a committeeof experts was appointed in order to do thejob quickly, but for the long-range plan-ning I thought that committees were notsuitable. Therefore, by decree-law, an officeor department devoted exclusively to plan-ning was set up. It will be a permanentoffice, which will not suffer the consequencesof changes of government. It will be mannedby statistical and other personnel, who willnot be subject to changes in orientation byreason of political changes, which unfor-tunately occur frequently in my country.

69


This planning office will work on the pro-gramming of national plans tied in withprovincial plans. It will try to furnish thebasic information for improving statistics,etc. It will standardize methods and pro-cedures in order to establish and maintaincollaboration among the different planningoffices at different levels throughout thecountry. In our country any plan encountersdifficulties under our form of organization,modeled as it is on that of the United Statesof America, in that each province is a stateresponsible for public health. Health plan-ning is thus much more complex in our coun-try than in others in which the nationalgovernment exercises jurisdiction over allthe territory.

Therefore, I proceeded to organize a con-ference of the Provincial Health Ministers,similar to this one, in order to convince themof the need for what I am saying. In thisway it was possible to establish a planningdepartment in each province; these fur-nished the bases for a general orientation inthe matter of planning. Furthermore, I sup-plied them with a glossary containing anexplanation of all the terms in current use,in order to standardize the terminology.

For the organization of these provincialplanning departments, we requested the as-sistance of experts of the Pan AmericanSanitary Bureau and also used other expertstrained in the School of Public Health ofthe University. Our School of Public Healthwas transferred to the University in order toavoid overlapping of functions. Today theSchool is producing good results, furnishingexperts who give us satisfactory aid. Withthe assistance of the personnel of the School,we intend to organize a seminar, or plan-ning course, for the training of all expertsof the province. We must use somewhat uni-form techniques and, thanks to this seminar,we expect to be successful.

There is an Argentine Public Health As-sociation in our country, made up not onlyof public health physicians, but also of en-

gineers, dentists, and all the technical per-sonnel engaged in public health work. TheMinistry has asked for the collaborationof this Association in organizing anotherseminar, on national and regional planning.

I attribute the greatest importance to thisplanning, for I believe that unplanned pro-grams lead to a waste of economic resourcesand of energy. In order to carry out theplanning we have intensified publicity, witha view to obtaining compulsory reporting onpreventable diseases. A law that I draftedthirty odd years ago has recently been re-enacted, because it was not being fully com-plied with. It is very hard to convince theprivate practitioner that he should at leastcooperate by reporting cases of preventabledisease in order that the health authoritymay follow up immediately with its aid.

The Ministry which I head has also beenconcerned with improving death certifica-tion. If we do not have satisfactory informa-tion on the causes of illness or death, it isimpossible to go ahead with planning or toset up priorities. We want the notificationto be recorded on the international certifi-cate. Persons who do not use it properly aresummoned to the Civil Registration Officeand are given an explanation of the case.In .this way awareness is increasing, and thedoctor will be able to serve public healthneeds.

We work with the Municipality of BuenosAires in planning courses for experts inhealth statistics. We actively promote thesecourses, two of which have already beengiven.

In general, the work of the Ministry islimited to the following functions: drawingup general health standards and bringingthem into general use; coordinating regionalplans; fulfilling international commitments;fostering scientific research; promotinghealth education among private practition-ers and among the general public; and plan-ning, executing, and evaluating the controlof endemic and epidemic diseases. The Fed-

Argentina 71

eral Government directs these campaigns,for endemic and epidemic diseases take noaccount of provincial boundaries. However,they always call for the collaboration ofprovinces and municipalities, for the latter,too, must understand what their duties andresponsibilities are.

We have transferred to municipal juris-dictions, such as that of Buenos Aires, andto the more important provinces, medicalcare departments which belonged to theFederal Government. We believe that themunicipalities and the provinces should de-vote themselves to medical care of indi-viduals, leaving public health care to theNational Ministry. We recommend espe-cially that the hospital not be limited topersonal care, but also be a health centerwhere preventive medicine is practiced,since, as you know, this is the most effectivesort of medicine.

All these health measures will not availto foster better individual conditions if edu-cation is not increased. First comes educa-tion and later health, or perhaps, healthcare and finally the economy. A person whocannot read or write cannot follow the ad-vice given him; nor can he work or produce.Before attending to the economic problemit is necessary to attend to health. This iswhat Dr. Horwitz, Director of the PanAmerican Sanitary Bureau, has been sayingfor a long time.

Among conditions which it is desirable toimprove, such as education, work, nutrition,and housing, it is essential to add the im-provement of recreational activities for theindividual. In my province the farmer andthe worker have adequate dwellings, a goodincome, and good food. However, when Sun-day comes they have no means of amuse-ment, and they go to the bars and drink toexcess. The next day they do not go to work.Alcohol brings with it domestic tragedy. Itnot only damages the individual, but alsoinjures the family and society. Therefore,I consider it imperative to give more em-

phasis to recreation, to the promotion ofsports among the less well-to-do classes, asa means of preventing alcoholism.

Geographic conditions in our countryvary widely. Argentina extends from semi-tropical zones to the south polar region, afact that gives rise to completely differenthealth problems. We have had to draw upregional plans and try to coordinate themwith those of the neighboring regions. Ofcourse, in our planning we have been andstill are giving special attention to thematter of priorities. I believe that greaterattention ought to be paid to the rural zone.Our country is essentially concerned withagriculture and livestock; that is the sourceof its production. sWe must improve housingand health conditions among our people,since in them lies the origin of our wealth.I think that what we call "city slums"-masses of people in insanitary dwellings inthe large cities-are of much less impor-tance than the betterment of housing condi-tions in rural areas. The former are locatedaround the large cities, and it is much morepossible to control their sanitation andpolice them than is the case with rural areas.

Argentina's chief health problems arethose connected with public water andsewerage services, although 75 per cent ofthe urban areas have them. But Argentinahas the peculiar characteristic of having alarge head and a feeble body. Large citiessuch as Buenos Aires, Córdoba, and Rosariohave all the services. On the other hand, inthe rural zones, where 33 per cent of thecountry's population dwells, running waterand sewerage systems are completely lack-ing. Consequently, the mortality rate dueto typhoid fever is still about 9.5 per cent,and that of gastroenteritis 7.5 per cent. Asfor mortality in the first year of life, theaverage is 62.6 per 1,000, but there are cities,such as Buenos Aires, where it amounts toonly 20. In some provinces the rate is ashigh as 133 per 1,000. The problem of mor-tality in the first year of life is very im-


portant for us. We believe that the child isthe most precious potential capital that anycountry possesses, and we accord it our bestefforts.

Tuberculosis has decreased greatly in ourcountry. We have a mortality rate of 15 per100,000. The most important parasitic dis-eases are Chagas' disease, ancylostomiasis,and malaria. About two million people areinfected with the first; and of these some15 per cent have clinical symptoms thatlead to cardiac deficiency before the ageof 50. Ancylostomiasis comes next in orderof importance; a million and a half peopleare infected with it, with a resultant de-crease in their productive capacity. As tomalaria, during the past year we have hadonly 4,528 cases. We are trying to stampout two foci of infection, the large one inEl Chaco, where work is going on with thehelp of the Pan American Sanitary Bureau,and another small one on the northern bor-der of the same province.

There are about 22,000 leprosy cases inthe country. A very well directed campaignhas been initiated, also with help from thePan American Sanitary Bureau, in theProvince of Entre Ríos; it will soon beextended to other provinces.

As to smallpox, I must make one commenton the report 1 of the Pan American Sani-tary Bureau which ascribes two cases toArgentina, one indigenous and the other im-ported. I believe that both are imported, forthe one considered indigenous was foundright on the frontier and no other casesoccurred. This leads to the conclusion thatimmunization in the surrounding region issatisfactory.

The distribution of physicians is an im-portant problem in Argentina, where it ismost uneven. It is estimated that in thecapital there is one physician for every 220inhabitants; in five provinces, on the otherhand, there is one physician for every 2,000

1 Document TFH/11 (Eng.), 8 March 1963, pp.18-27.

inhabitants. In the country at large there isan average of one physician for every 657inhabitants, which is not a bad proportion.What we are weak in-and for this reasonwe are promoting the School of PublicHealth-is public health physicians; thereare only about 200 accredited ones in thecountry, which is an insufficient number.It is the same with nurses; in the entirecountry there are 28,000. However, theworst aspect is not their small number buttheir low level of competency. Conse-quently, various nursing schools are now inoperation, and the situation is slowly im-proving.

There are 6.2 hospital beds for every1,000 inhabitants. In the polyclinics thereare perhaps too many beds; in Buenos Aires,for example, there is a daily average of2,400 unoccupied beds. This really meansthat distribution is unsatisfactory, sincebeds are lacking for some hospital patients,while for others there is an excess of beds.For this reason I requested and obtained thetransfer of regional hospitals to the munici-pality; this will permit rationalization. Weare trying to establish wards for the men-tally ill in all the hospitals, and many nowhave them. We believe that the only wayto relieve congestion in the hospitals is toestablish wards for the mentally ill, as wellas diagnostic centers in order to avoidaccumulation in the former.

With respect to housing, we have only 50per cent of the dwellings we need. Accord-ing to estimates made in 1952, there was ashortage of about 1,300,000 dwellings. Withthe population increase and the lack ofbuilding construction resulting from the in-flation, I believe that the present need is for2,500,000 houses.

A related factor is capacity to pay formedical services; we have made specialstudies of this. Fifteen per cent of the popu-lation is capable of paying fully for carewhen they are sick. On the other hand, we

Argentina 73

estimate that about 60 per cent of the peo-ple depend upon mutual insurance plans.Let me say in passing that the aid given bythe mutual firms is never complete, butonly partial. National health insurance isindispensable, but it is a complex matter,and a Ministry, transitory as mine is to acertain extent, has not been able to achieveit. Twenty-five per cent of the sick aretreated without charge by the State, theprovinces, or the municipalities, but I havenow imposed fees, on the premise that somepeople can pay something in order thatothers may get better care. We have estab-lished fees in all the national hospitals inorder to create in the people an awarenessthat it is necessary to buy health becauseit, too, is important as is bread, the movies,and anything else.

The total financial resources at the dis-posal of the Ministry amount to no more

than 4 per cent of the national budget. Thatis a very low figure, but no matter how hardwe press the Ministers of Economy and Fi-nance, it is never increased.

Finally, the most important zoonoses arehydatidosis and brucellosis, which have re-percussions not only on the economy butalso on human life. The Pan AmericanZoonoses Center is located in the Azul re-gion; it operates very well. I have asked theMinistries of Economy and of Agricultureto grant it funds, for it is rendering an ex-tremely important service, both to Argen-tina and to other Latin American countries.

I have limited myself to a summarystatement, but I do not want to end it with-out giving special thanks to the Pan Ameri-can Sanitary Bureau for the way in whichit has strengthened our mutual relations andfor the very effective help it has furnishedus in attaining our goals.

ADDRESS BY THE SURGEON GENERAL OF THE PUBLIC HEALTH SERVICEOF THE UNITED STATES OF AMERICA*

Presented byDR. JAMES WATT

Chief, Division of International Health,Public Health Service

I have the honor to present some thoughtswhich the Surgeon General, Dr. Luther L.Terry, has asked that I express to theMinisters here. It is a great privilege forme to present Dr. Terry's text, which readsas follows:

"It is an honor to participate with youin this highly important Meeting. My dis-tinguished colleagues from the Americasrepresent the spearhead of a dynamic move-ment to improve the health of the people ofthis Hemisphere. No other group has soclear a perception of the true significanceof public health measures to our mutualprogress. Indeed, we share a long-standingmutuality of interest which has grownstronger and deeper over the years.

"Our purpose here is to plan the stepswhich need to be taken over the next tenyears to achieve the goals of the Charterof Punta del Este. It is a very serious pur-pose. It is very necessary. And it is by nomeans simple.

"We must ask ourselves some searchingquestions. What do we need in order toreach our health goals? Which goals shouldbe met first and which need to await furtherdevelopments? What are our economic andsocial capabilities? How do these factorsaffect rational planning?

"These are not easy questions to answer.But they must be faced squarely if we areto substitute forethought for chance, direc-tion for haphazard activity. Planning is the

* Presented at the second plenary session, 15April 1963.

74

most effective method we have for achievingnational and international health goals inthe present period.

"I want to share with you today some ofmy thoughts on planning health programs,based on the experiences of the UnitedStates of America in recent decades. Notthat we have any magic formulas or thatwe have uniformly applied the principles ofplanning to achieve fully our stated healthgoals. Certainly we in this country fall shortof providing our people with the full rangeof high quality health services now possiblethrough the application of scientific knowl-edge. We have discovered, however-largelythrough trial and error-that some thingswork well and produce desirable results.

"There is one observation that underliesall our discussions this week: the levels ofexpectation of people everywhere are rising.People are no longer satisfied with things asthey were, or as they are. This soaring as-piration is the hope of the future; it is alsothe challenge of the present.

"Nowhere is this challenge sharper thanin the field of health. People want goodhealth for its own sake-so they can be freefrom haunting fears, so they can see theirchildren grow strong and vigorous, so theycan live a full life. And health is also a re-source which permits the realization of othergoals and aspirations.

"It is little wonder, then, that health hascome to ,be regarded as a right on a par withthe other basic rights of mankind. The con-cept that society has a stake in health and

United States of America 75

should intervene actively to improve it maybe of recent origin, but it is unmistakable.

"There is widespread recognition amongAmerican statesmen that health is a majorconcern of the American people. It rankswith education and economic security as apublic good to be sought through nationalaction.

"This has been an accelerating trend overthe past decades; it received its greatestimpetus, perhaps, during World War II.Wartime health research, pursued on a scalenever before attempted, opened new trailsfor peacetime exploration. New departures-in medical care, in emergency healthmeasures, in professional training-demon-strated what could be accomplished.

"It is difficult to overestimate the impactof these accomplishments on the popularmind. Leaders throughout the country werequick to perceive the great shifts in popularaspirations for health. They sought the ad-vice and cooperation of professional healthpersonnel and of hospital and medical lead-ers on new health plans and programs.

"Even as the war was ending, nationalprograms for the construction of hospitalsand the expansion of medical research wereenacted into law. Both these programs havegrown and broadened over the years. Theyhave had the highest priorities in our na-tional health policy. They have gained inpopular and professional support year byyear.

"Within five years after the close ofWorld War II, Federal legislation had beenenacted or proposed to provide nationalimpetus in many other areas-heart diseaseand cancer control, for example. And in thepast decade, a series of programs have beenstarted or greatly expanded to meet thehealth problems of our increasingly complexphysical environment.

"In the pursuit of these national healthgoals we have uncovered large areas of un-met needs. From the point of view of plan-

ning for health programs, however, severallessons can be drawn.

"First, health is an important element ina nation's drive toward a better and a moreabundant life for its people. The best possi-ble use of the nation's health resources andhealth agencies represents the highest typeof statesmanship. Sound health programsreflect sound leadership. And they promoteeconomic and political stability.

"Second, national health problems call fornational action. If a job is important enoughto be done, if a problem affects a consider-able portion of the people, then the decisionto meet it must be made at the highest levelsof government. It must be a national deci-sion, arrived at by political leaders andhealth leaders and concurred in by manygroups which have a part to play in itsimplementation.

"Let me illustrate from the experience ofmy organization, the U. S. Public HealthService. In 1955, after considerable studyand discussion, a decision was made todevote concentrated national attention tothe health problems of American Indians.Health conditions among these people weresimilar to those which prevailed in thegeneral population half a century ago.There was agreement that this posed aserious problem which was of importanceto the entire nation. Congress enacted legis-lation which made the Public Health Serv-ice responsible for administering a compre-hensive program of preventive and curativemedical service for American Indians andAlaska natives. The Service became, in ef-fect, the family doctor, community hospital,and local health department for the Indianpeople.

"After the decision was made, the othersteps in the planning process were begun:survey and analysis of the situation; de-velopment of a planned program; arrange-ments for funding; and actual operation ofthe program. New hospitals, health centers,and clinics were built. The professional


health staff was expanded. Preventivehealth measures were put into effect. Watersupply and waste disposal methods wereimproved.

"In the eight years since this program wasbegun, the infant mortality rate among In-dians has declined 40 per cent. Tuberculosis,once the leading cause of death among In-dians, dropped to eighth place, with a 50-per-cent decline in the death rate in the lasteight years. And there are other equallygratifying results, and perhaps of greaterlong-range significance. More and more In-dians are presenting themselves to hospitalsand clinics; are assuming more individualresponsibility for improving their health;are participating in program planning; andare being trained as practical nurses, sani-tation aides, and community health edu-cators.

"I do not want to leave the impressionthat all the problems have been solved.Even with the advances that have beenregistered, American Indians rank far be-hind the general population in the generaldeath rate and in life expectancy. The loweconomic levels, the barriers of languageand culture, the problem of. vast distancesare formidable obstacles. But a good be-ginning has been made. There are brighterprospects for liberating these Americansfrom the bondage of illness and for a futurewhen they may well assume the majorresponsibility for their own health services.

"The third observation I would makefrom our experience is the merit of the cate-gorical approach to the solution of healthproblems. Most of the health developmentsin this country have been of a categoricalnature.

"The health charter is very broad,whether we look at the World Health Or-ganization definition of health or at thegoals of the Punta del Este declaration. Asone of our first steps, therefore, we need todetermine what is involved in the term

health. The yearning for better health iscertainly real. Yet people are not alwaysclear as to the meaning of health, especiallyin terms of the measures that organizedsociety might take to improve it. Healthneeds vary from place to place, from coun-try to country, from region to region.

"There is a great deal to be said, there-fore, for breaking down our health problemsinto 'bite-size' packages. Specific programs,related to specific goals, can more readilybe seen and understood. Popular supportcan more easily be mobilized. In this coun-try, in fact, voluntary citizens' associationshave arisen to generate action by bothgovernmental authorities and private insti-tutions against specific problems.

"In categorical programs, too, resultsmay be obtained more quickly and progressmeasured more easily. We can move, forexample, in an orderly series of steps fromdisease control, to containment, to eradica-tion.

"There are at least three types of cate-gorical approaches to health problems:

"1. Concentrating on specific diseases,such as malaria, tuberculosis, or smallpox.

"2. Working on the health problemswhich are related to specific economic ob-jectives. If a country cannot reach the goalsset for its farms and factories because poorhealth is draining the productivity of itsworkers, then the health problems musthave first priority. This was the situation,you will recall, in the initial stages of theprogram of the Institute of Inter-AmericanAffairs, which had as one of its major pur-poses the expansion of the rubber, tin, andmica industries. Much of the program hadto be concentrated on the solution of healthproblems.

"3. Building the services and facilitieswhich safeguard the physical environment,such as community water supplies, foodsanitation, refuse and waste disposal, andpollution control.

United States of America 77

"All.of these approaches are visible andconcrete. They provide a focus of effort onwhich political leaders and health workerscan work together without sacrifice of prin-ciples. The demands of expediency need notthrow sound planning out of balance. Theycan actually be incorporated into the plan-ning process. There are, of course, adminis-trative hazards in piecemeal growth. But ifhealth leaders keep their organizations flex-ible they can, on the one hand, take ad-vantage of all opportunities for improve-ment; and, on the other, they can worktoward a synthesis to direct their attentionto the whole man, the whole community,and the whole nation.

"Planning, in essence, is the mobilizationof people, resources, and facilities to thebest possible effect so that problems aresolved. Planning that is not specifically re-lated to the problem at hand is, at best,unrealistic and at worst, sterile. We are notplanning for the sake of planning, we areplanning for something.

"Planning is doing. It is a continuous ad-ministrative process. How many 'soundplans,' drawn up by knowledgeable andwell-intentioned people who are distantfrom operations, have gathered dust? Plan-ning must be closely related to day-to-dayoperations. Such planning, plus a deep un-derstanding of the problems, will make anysolution easier to arrive at. It will enablehealth leaders and health administrators,for example, to look beyond a specific wayof working or a particular kind of organiza-tion. Instead, they can evaluate what isavailable against what is needed and mo-bilize all the resources that can help.

"There is not a country in this Hemi-sphere which does not contain untapped re-sources and competencies which can befocused on health needs. If these resourcesare not used, many programs which looksound on paper may face insurmountable

difficulties or, worse yet, may be doomedto early failure.· "The caliber and kinds of personnel avail-able also play an important part in pro-gram planning and administration. Almosteverywhere, we find professional healthmanpower to be in short supply. Certainly,the shortages have hampered health serv-ices in this country. This suggests two im-portant steps in sound program planning.First, the training of auxiliary and nonpro-fessional workers should have a high pri-ority in all organizations. Second, the or-ganization should be such that maximumuse is made of highly trained professionalpersonnel. Routine details should be dele-gated to auxiliary or less highly specializedworkers. We in this country still have agreat deal to learn in using these workersmore effectively. And the need is no lesssignificant in other countries of this Hemi-sphere.

"I have tried to indicate some of the prin-ciples and practices of planning that haveworked well for us. I know many others willbe considered during the course of yourdiscussions this week.

"Above all, we must move forward withall possible speed to meet the historic healthgoals envisioned under the Alliance forProgress. The Charter contains both spe-cific and general objectives. During thecourse of this conference, we should dedicateourselves particularly to achieving the cate-gorical goals and to plan continuing andlong-range programs to meet the more gen-eral objectives. If we devise a system forsetting priorities, if we decide which diseaseswe can nominate for extinction, if we iden-tify the health projects we wish to concen-trate on in an orderly progression over thecourse of the ensuing decade, then we canachieve the goals which have been set.

"We have the professional and technicalknowledge to do the job. We have numer-ous examples in this Hemisphere of nations


which mobilized quickly to meet and to con-quer health problems. We have vast popularsupport among people who are eager forbetter health.

"We all share a solemn responsibility. All

of us in the health and health-related fieldsare, in the words of the Charter, part of a'vast effort to bring a better life to all thepeople of the Continent.' We must now doour utmost to make that effort a reality."

ADDRESS BY THE UNDERSECRETARY OF STATE FOR PUBLIC HEALTHAND SOCIAL WELFARE OF HONDURAS

DR. CARLOS A. JAVIER


We are now gathered in this First Meet-ing of the Task Force on Health at theMinisterial Level to discuss far-reachingmatters concerning the health of the peoplesof the Western Hemisphere. Faced with re-peated frustrations, people are earnestlyseeking fresh hope through the promisinghorizons opened by the Alliance for Prog-ress. They put once more in the hands oftheir leaders their trusting faith in theeternal postulates of human rights, whichhave not yet come to full fruition in mostof our countries, keenly hoping that thistime positive plans for their well-being willresult.

At this Meeting we are going to discussResolution A.2 of the Charter of Punta delEste relating to the Ten-Year Public HealthPlan of the Alliance for Progress. Repre-senting our countries, we bring with us thehopes and good faith of our fellow citizenswho rightly aspire to the betterment of thegeneral conditions of their lives and to thepermanent enjoyment of the good thingsnourished by the doctrine of democracy, thebeacon which sets the course of this con-ference. Resolution A.2 of the Charter es-tablishes a series of ideal principles forimproving the health of the inhabitants ofLatin America, not only as a concept ofnatural law, which establishes completewell-being as the right of every human be-ing, but also as a factor of high priority inthe social and economic progress of ourcountries.

Pursuing these lines of thought, our coun-

try has already presented to the appropri-ate organization an initial plan for immedi-ate action to be developed within two years,with plans for the ten-year period that theAlliance for Progress embraces. It is clearto everyone that to draw up a ten-year pub-lic health program is an enormous task. Itdemands extraordinary resources, from thetechnical as well as the economic point ofview. With this in mind, our Governmentbelieves that the aid offered by the PanAmerican Sanitary Bureau and the Alliancefor Progress should be taken advantage ofimmediately in order to plan this project ina speedy and efficient manner.

It is undoubtedly true that work plannedin detail offers surer and more definite re-sults, but the solution of our health prob-lems permits of no delays, so pressing is thecharacter they have assumed. The problemsare so acute that we must face them imme-diately. We must avoid insofar as possibleexcessive bureaucratic transactions and re-duce to a minimum the technical require-ments that frequently hold up the execu-tion of projects planned and studied byspecialized institutions of our countries,even with the aid of international experts.

We speak in this manner because we havehad that very experience, for example, inconnection with the system of potable watersupply in Tegucigalpa, a pressing problem.As such, it was the object of urgent studies,and its solution will be possible, thanks tothe attention accorded it by the Inter-American Development Bank, which set a

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reasonable time for meeting the require-ments and furnished the necessary loan.This speed should be the hallmark of alloperations aimed at solving social and eco-nomic problems, since undue delays willseriously affect the objectives which theAlliance for Progress plans to achieve.

The demand for extraordinary funds tosupplement the financial credits grantedour projects also gives our budding econo-mies some concern. It is not always possibleto obtain additional funds because of thetightness of internal credit.

For the Government of Honduras, thecompletion of projects now being executed,as established in Resolution A.2 (par. 2-a)of the Charter of Punta del Este, meansthat the international aid it has been receiv-ing will continue, as will its own commit-ments, without any loss of the resources thatthe Alliance for Progress might possiblygive it. Thus, programs previously initiatedin accordance with specific agreements willnot be combined with new programs.

Since this is a high-level conference, itdoes not seem idle to express these generalconsiderations. Stated at an opportune time,they could be useful in accelerating the Alli-ance for Progress. And since we have comehere to present the health problems of theAmericas, permit me to outline to the Minis-ters present at this Meeting the outstandingproblems that my Government considerspossible of solution within the time em-braced by the programs of the Alliance.

ENVIRONMENTAL SANITATION

In the matter of environmental sanita-tion, our country faces the problems of po-table water supply and of disposal of sewageand waste. It can be said that up until 1961only 15.8 per cent of the total populationwas directly benefiting from potable watersupply systems. Since the total population,according to the 1962 census, is 1,886,440,there are still 1,588,383 inhabitants who do

not enjoy this important service, and 298,057are supplied with water whose potability wecannot guarantee. The urban population isthe most favored, yet this group representsscarcely a fifth of the total population. Al-though the distinction between rural and ur-ban population in our area is virtually non-existent, the distinction has been made forpurely administrative reasons. In order tocarry out national plans for water supplysystems, the Government of the Republichas two technical organizations: the Divi-sion of Environmental Sanitation, under theNational Department of Public Health,which is responsible for water supply andthe installation of latrines in communitiesof up to 1,000 inhabitants; and the Na-tional Autonomous Water Supply and Sew-age Disposal Service, which is responsiblefor the same task in communities of morethan 1,000 inhabitants. Viewing the task inits national dimensions, both organizationshave drawn up pilot programs, for immedi-ate execution within their respective spheres,which can serve as precedents for otherprojects covering the needs of the rest ofthe country.

The Division of Environmental Sanita-tion intends, if it obtains adequate financ-ing, to install potable water services andlatrines in 80 rural communities, the financ-ing for a two-year plan being as follows:

LempirasGrant from UNICEF ..... 209,050.00Grant from Alliance for

Progress .............. 548,022.27Municipal grant ......... 243,011.28Grant from Ministry of

Public Health ......... 158,000.00Total .............. 1,158,083.55

The Division of Environmental Sanita-tion proposes to develop this program in thefirst two years, beginning this year, pro-vided the financial aid becomes available intime. This program will benefit about 50,000

Honduras 81

inhabitants in 1964, and its capacity willallow it to service the normal increase inthe population until 1972.

In addition, the Division will carry out,at the same time as the water supply pro-gram for 80 rural communities, a programfor the installation of latrines for these com-munities at a cost, for the two-year period,of 78,477.50 lempiras. The financing willbe as follows:

UNICEF ................Municipal ...............Ministry of Public Health..Private (sale of latrine

slabs) .................Total ...............

Lempiras12,000.003,027.50

17,850.00

45,600.0078,477.50

It is interesting to note the share that thelocal communities will have in carrying outthese programs.

The National Autonomous Water Supplyand Sewage Disposal Service is a decentral-ized institution of the Public Administrationof Honduras, especially created as a tech-nical organization to represent the State inthe functions within its purview. As it wasrecently created, in 1961, it has not yet hadtime to make the necessary surveys. How-ever, fully aware of its responsibilities tothe programs of the Alliance for Progress,it has drawn up construction plans for watersupply systems, and for extensions and im-provements of potable water systems for agroup of nine urban communities includedin our two-year plan. The cost of 8,520,000lempiras will be financed as follows:

LempirasAlliance for Progress.... 2,100,000.00Inter-American Development

Bank ............. 4,800,000.00Government ........... 1,620,000.00

Total ............. 8,520,000.00

COMMUNICABLE DISEASES

Malaria eradication. The campaign foreradication of malaria continues its normalpace in accordance with the agreements con-cluded by our Government with the Agencyfor International Development, the UnitedNations Children's Fund, and the WorldHealth Organization. This program is in-cluded in the two-year plan and complieswith one of the objectives set forth in Reso-lution A.2 of the Charter of Punta del Este.The cost for 1963 and 1964 is 2,678,000lempiras, to be financed as follows:

LempirasGovernment of Honduras. 1,200,000.00AID .................. 1,478,000.00

Total ............... 2,678,000.00

These figures do not include the valuableaid given by the World Health Organizationand the United Nations Children's Fund.

Tuberculosis control program in the ruralarea of Honduras. On the basis of biostatis-tical research on this disease, the Govern-ment of Honduras drew up, at the timewhen it introduced improvements in thepneumology services of the health centers,a collective program employing methods ad-vised by experts for the investigation andcontrol of tuberculosis in rural areas, andbeginning with a selected area of the coun-try, as the first step of a national campaign.The specifications and other details are out-lined in the two-year plan we have men-tioned. We wish merely to note that theselected area has a population of 150,000inhabitants who, we hope, will be coveredwithin two years.

Funds to finance this program will beobtained as follows:

LempirasUNICEF ............... 170,000.00Alliance for Progress ...... 371,056.18Ministry of Public Health. 402,112.36

Total .............. 943,168.54


Campaign against leprosy. In 1960, theGovernment of Honduras began a programfor the investigation and control of leprosyin the southern part of the country, withthe technical advisory assistance of theWorld Health Organization. The Govern-ment created a mobile unit with a leprolo-gist, the Choluteca Health Center beingused as a base of operations. Appraisal ofthis program showed that leprosy is an in-sufficiently investigated problem; largerfunds are needed for its study. Our two-yearplan contemplates an approximate expendi-ture of 39,074 lempiras.

Smallpox control. In 1962 the Governmentof Honduras intensified mass vaccinationagainst smallpox, with the aid of the PanAmerican Sanitary Bureau, which furnishedsmallpox vaccine. The application of vac-cination has now been systematized andgoals have been set for each health center.In spite of the Government's interest in thiscampaign, lack of funds and personnel hasprevented it from undertaking a formaleradication campaign. I might note thatfortunately no case of smallpox has beenrecorded in the country in the last 35 years.

Diphtheria, pertussis, tetanus vaccina-tion. The prevention of pertussis, tetanus,and diphtheria has not reached a satisfac-tory level either, because of lack of re-sources for acquiring the vaccine. The sameapplies to vaccination against poliomyelitis.

NATIONAL NUTRITION CAMPAIGN

The incidence of the syndromes of mal-nutrition in the country is alarming, espe-cially among children. The problem isclosely related to the lack of health educa-tion among the people and to general pov-erty, factors that work together to producethe tragic situation.

The solution at the national level callsfor enormous financial and technical re-

sources, together with a long period of sys-tematic activities capable of changing themental attitude of the inhabitants, who donot know how to take advantage of existingresources. Nevertheless, a program has beendrawn up, at the local level, and includedin our two-year plan; that is, a coordinatednutrition program in the execution of whichthe Ministries of Public Health, NaturalResources, and Education take part.

The program has been formulated by aninterdepartmental coordinating committee,with the aid of the Food and AgricultureOrganization and the World Health Or-ganization and a financial grant from theUnited Nations Children's Fund.

Financial resources for the developmentof this program are as follows:

LempirasUNICEF .............. 121,904.00Government of Honduras. 191,330.00

Total .............. 313,234.00

The time available to enumerate ourproblems here is limited, but I should notfail to point out, even though in summaryform, other basic factors in the success ofthe Alliance for Progress. Our health pro-grams will suffer if careful attention is notgiven to the integration of the general pub-lic health services; to the training of per-sonnel at all levels; to health education ofthe public; and to continuing the NationalHealth Plan by establishing other physicalentities to execute the general services, set-ting up mobile units for medical care inrural areas, and constructing the new gen-eral hospitals-San Felipe in Tegucigalpa,Leonardo Martínez in San Pedro Sula, At-lántida in La Ceiba, and Occidente in SantaRosa de Copán. All this has been included inour two-year plan.

The Government of Honduras estimatesthat to accomplish the minimum plan setforth above, a total of 21,099,948.17 lem-

Honduras 83

piras will be required. The details of thecosts are as follows:

LempirasWater supply construction

in rural areas ........ 1,158,083.55Water supply systems in

urban areas ..........Latrine program .......Tuberculosis campaign ..Leprosy campaign ......Nutrition campaign ....Training of personnel...Construction of health

centers .............Rural mobile units......Water supply for

Tegucigalpa .........Hospital construction and

study of project for SanFelipe GeneralHospital ............

Antimalaria campaign ..Health education ......

Total .............

3,520,000.0078,477.50

943,168.5439,074.00

313,234.00103,200.00

712,000.00959,200.00

5,000,000.00

5,127,400.002,678,000.00

468,110.5821,099,948.17

Financing

UNICEF ............. 521,148.00Alliance for Progress .... 9,164,548.55Municipal ............. 246,038.78Central Government ... 6,322,612.84Inter-American Develop-

ment Bank .......... 4,800,000.00Private ............... 45,600.00

Total ............. 21,099,948.17

I wish to state in this assembly the deepinterest that the Government of Hondurashas in bettering health and general condi-tions in Puerto Cortés, which may be con-sidered the best Central American port onthe Atlantie coastline. In this connection,the Ministry of Public Health has been

receiving for some years both technical as-sistance from the Pan American HealthOrganization and the aid of the United Na-tions Special Fund for preliminary studieson the sanitary fill in this port.

The Government of Honduras is anxiousfor the problem of Puerto Cortés to havepriority in the list of solutions that theAlliance for Progress is trying to reach. Wemust not fail to note that, as a result of roaddevelopment and economic integration inCentral America, Puerto Cortés will in-evitably become a center of commercialtransport for the Republics of Guatemala,El Salvador, and Honduras. This fact givesemphasis to the importance of whatevereffort is made to better conditions there.

In the name of the Government of Hon-duras, I take this opportunity to expressour great interest in this Meeting of theTask Force on Health and our appreciationto the Secretary General of the Organiza-tion of American States, Dr. José A. Mora,and to the Director of the Pan AmericanSanitary Bureau, Dr. Abraham Horwitz, itsorganizers. On behalf of my Government,I should also like to state our gratitude tothe Inter-American Development Bank forthe favorable reception it has accorded ourrequests for financing for development. Andbefore closing, I wish to express once moreto the Government of this great nation, theUnited States of America, our acknowledg-ment of its continuing aid to our healthprograms, and to voice our fervent hopethat the ideals of President John F. Ken-nedy, supported by the programs of the Alli-ance for Progress, may take root in a formthat will preserve the peace and lead tothe attainment of well-being in the Hemi-sphere.

ADDRESS BY THE MINISTER OF PUBLIC HEALTHOF URUGUAY

DR. APARICIO MENDEZ


In order to facilitate the task of the com-mittees, we shall give an account of thesituation in Uruguay with respect to healthconditions. Our accomplishment is small,measured by the yardstick of our duty asgovernment officials, and less still measuredby our aspirations as citizens of America.

The status of health in Uruguay can beput in optimistic terms from the continentalstandpoint if we take into account the factthat, by virtue of its geographic locationand climate, the country is not exposed toany of the tropical diseases, and the terrane,the mode of life, and the homogeneity ofthe population facilitate the carrying outof curative and preventive plans.

Public health services, basically under theMinistry of Public Health, represent 9.8per cent of the general budget, which allo-cates to health 278,000,000 pesos, brokendown as follows: administration, 13,000,-000; research, 9,000,000; and care and pre-vention, 256,000,000. It is of interest tonote that the public health budget, whichhas now reached the figure of 278,000,000pesos, was barely 74,000,000 pesos in 1959.

By means of continued efforts we havebrought about maximum immunizationagainst smallpox and have virtually elimi-nated typhoid fever and diphtheria, and lastyear we carried out mass poliomyelitis vac-cination of the susceptible population withSabin vaccine.

We have at our disposal a special andhighly efficient system for handling tubercu-losis control, by means of care and by pre-

ventive and social measures. For this pur-pose the Ministry of Public Health has2,742 beds throughout the country; for thesepatients, care is wholly gratuitous. In re-cent years the number of deaths has de-creased to below 500 a year (a rate of 15.9per 100,000 inhabitants), giving a propor-tion of six beds for each death. As is evi-dent, tuberculosis is declining throughoutthe world, but there is one difficulty, of rela-tively recent appearance, the resistance ofKoch's bacillus to modern therapeutic meth-ods. The Ministry is giving this problemparticular attention, and coordinated ac-tivities are being organized through jointresearch in the different specialized labora-tories.

As to venereal diseases, in spite of theincrease in the incidence of primary syphiliswitnessed in recent years, advances in thera-peutic methods and in health education leadus to hope that this group of diseases willremain limited and decline in importance.For many years the country has had a lawthat provides for free antivenereal treat-ment, without discrimination by reason ofthe financial means of the individual, andeven permits concealment of the individ-ual's identity, so as to ensure that reasonsof a social nature do not prevent treatment.

The nutrition survey made last year withthe aid of the U. S. Interdepartmental Com-mittee on Nutrition for National Defensehas shown that we exceed the average quo-tas of the National Research Council withrespect to calories, proteins, calcium, iron,

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Uruguay 85

and minimum vitamin A. We are deficientonly in vitamin C, thiamin, riboflavin, andniacin.

Measures have now been undertaken forthe iodization of salt, in order to make adefinite attack on endemic goiter, whichoccurs in three northern departments (outof the 19 departments of the Republic).Plans are also being made to initiate cam-paigns at the national level against hydatid-osis, Chagas' disease, and leprosy, whichis a regional rather than a national problem.

Perhaps the problem of greatest impor-tance is infant mortality, in spite of thefact that Uruguay has one of the lowestrates in this field. An important nationalcommittee, composed of representative tech-nical personnel from all the specialized serv-ices and institutions, has been set up tomake preparations for an advisory congressthat will lay plans for a large-scale cam-paign to combat this problem.

We can say that once the medical carestage is completed and preventive measureshave been energetically initiated, we shallenter fully into this campaign, expandingit at all levels. In this connection, mentionshould be made of the work done in fivenorthern departments, with the aid of UNI-CEF; the experience there enabled us to doa great deal of health education and fur-nished us with valuable statistical materialneeded for undertakings of greater scope.In the city of Las Piedras, near the capital,a jointly sponsored pilot center has beenset up and is already yielding results.

With respect to medical care, we have atour disposal 14,000 beds in 30 primary cen-ters, including departmental centers, andmore or less the same number of auxiliarycenters, as well as first-aid stations. In thecapital the services must be completely re-organized, for in general they are locatedin old or inadequate buildings. In this fieldthe psychotherapeutic services are the mostpressing problem; these must be completelyreorganized in a form compatible with the

technical needs of a group of about 5,000patients.

It is important to mention the fact thatour country has a low birth rate (less than20 per 1,000 inhabitants) and a low mor-tality rate (about 8.5 per 1,000 inhabitants).Thus there is the problem of the aging ofthe population, with the concomitant in-crease in the prevalence of diseases charac-teristic of advanced age. This explains thenumber of those being cared for in psycho-therapeutic services. Furthermore, studiesare being made in geriatrics, a field to whichthe Ministry is devoting special attention.

Throughout the country, which covers187,000 square kilometers, the Ministry ofPublic Health maintains maternity serv-ices, providing free care. With a total of 605beds, they handle deliveries which representmore than a third of the total annual birthsin the country (55,000). With this numberof maternity beds, and on the basis of 85per cent occupancy, the number of deliveriesattended can be raised to more than 31,000,or more than 50 per cent of the births. Thisfigure can be reached through intensifiedhealth education work, as is now being done.

Through special efforts, the campaign isbeing equipped with modern medical careservices, including polyclinics, which willenable us to keep up to date.

As to personnel, in spite of the fact thatUruguay has one physician for every 800inhabitants (2,600 in all), it is necessaryto increase the number of technical staff inthe official medical care services and to ob-tain a suitable proportion of specialists, aswell as personnel in the auxiliary services:dentists, midwives, nurses, health visitors,and sanitary engineers. The shortage innursing personnel (nurses and nursing aux-iliaries) is the most serious. As to figures,we can say that we need nursing personnelto fill about 3,000 positions in all. Theexpansion of the School of Health, whichtrains nursing personnel, is under study.Isolated courses undertaken by way of ex-


periment will be completed by setting uppermanent and higher-level organizationsdesigned to train personnel in hospital ad-ministration and management and to estab-lish further training courses for auxiliarypersonnel.

The preventive services, which are theresponsibility of a division of the PublicHealth Ministry, are in the process of or-ganization and need a new structure. Morethan 130 polyclinics call for properlytrained health personnel and plans of workthat will avoid interference by a series ofparallel services which have been estab-lished without any uniform standards.

We need to reorganize our laboratories inorder to be able to carry out a sound nutri-tion policy in accordance with the newBromatological Code, which is now understudy in Parliament, and to increase theproduction of BCG, smallpox, tetanus, andrabies vaccines, as well as the training ofresearch personnel.

Rural health services are to be graduallyextended in accordance with a plan understudy. There is now under consideration inParliament a social development plan inconformity with the Alliance for Progressprogram. It covers school and hospital con-struction, including 18 regional polyclinichealth centers in the departments of theinterior and 22 of different categories forthe capital, at a cost, for public health, of78,000,000 pesos. When this step is com-pleted, we shall be able to tackle the con-struction of modern centers for psycho-therapeutic services.

The large-scale road construction plancarried out by the Ministry of Public Workswill obviously have repercussions on everyaspect of national life, and especially thehealth aspects. In this connection, the in-stallation of water supply and sewage dis-posal service, over and above the generalplan under way, is urgent for a group of im-portant population centers that have sprungup near the capital without due provisionhaving been made for these services. Never-

theless, it is gratifying to note here thatMontevideo (the capital, with 1,000,000 in-habitants, representing 42 per cent of thepopulation) has potable water service for90 per cent of the population and sewerageservice for 75 per cent. In the cities of morethan 10,000 population, 60.6 per cent of thepeople have potable water service and 33.6per cent have sewerage service. In townsof 2,000 to 10,000 population, the propor-tion is 35.7 and 2.7 per cent, respectively.In all, 56 per cent of the country's popula-tion has potable water service and 39.7 percent has sewerage service. There are 25cities of more than 10,000 inhabitantsand 49 towns with from 2,000 to 10,000inhabitants.

As to standardization, studies are beingmade for the revision of legislation govern-ing medical care, which, though generous, isincomplete, and for the changes requiredto complete the preventive services. Finally,plans are under way for drafting a Code ofPrivate Medical Care with the aim offostering activities in this field, solving someof the serious difficulties that affect privateinstitutions, and establishing a uniform sys-tem that will enable us to deal with theproblems on an organized basis.

We conclude by noting that the currentwork of the Ministry of Public Health ofUruguay is made up of the following threebasic elements:

1. Technical planning of all activities.2. Raising the technical level of the pro-

cedures for organization and administrationof the present services and of those beingcreated.

3. Placing medical care and preventiveservices within reach of people living invillages or isolated in rural areas. If this isa basic principle that ought to be carried outin every country, it is especially importantthat Uruguay, whose production consistsof livestock and farm products, should im-prove the environment of the farmer, sincehe is the basic factor in increasing pro-duction.

ADDRESS BY THE MINISTER OF PUBLIC HEALTH ANDSOCIAL WELFARE OF PERU

DR. VICTOR SOLANO CASTRO

Presented at the Third Plenary Session16 April 1963

I have the honor to extend the most cor-dial greetings to the distinguished repre-sentatives of the sister nations of the Ameri-cas, on behalf of the Government of Peruand in my own name. We are gathered heretoday for the noble purpose of studying howthe plans of the Alliance for Progress canbe made a reality in the field of publichealth. Health is a pillar basic to the struc-ture of the economic and social developmentwe all desire so fervently. That developmentwill constitute a solid barrier protecting theChristian ideals of freedom and democracyof the peoples of America, who so ferventlydesire social justice and a decent standardof living.

Health and well-being know no frontiers.They are propitious fields for internationalcooperation. Their basically human aspecthas led to the long continuance in our Hemi-sphere of that fruitful cooperation of whichthe Pan American Health Organization isthe living symbol. This agency has been anexample to the world, throughout the 60years of its existence, of what can be donewhen the ideals are pure and the sole objec-tive is the happiness of the people.

Peru, a country which traditionally re-spects its international commitments, hasadhered decidedly and enthusiastically tothe crusade which the Alliance for Progressrepresents. Peru is determined, in preparingits plans and programs, to solve its prob-lems, such as lack of sanitation, ignorance,malnutrition, and in sum, poverty. Despitetheir magnitude, these problems will not

break the spirit of the peoples of America,who are now vigorously rising to the chal-lenge of overcoming them.

The main health problems of the Hemi-sphere are set forth in the Charter of Puntadel Este, and especially in the Ten-YearPublic Health Program of the Alliance. Itwill be necessary to concentrate on themboth our national efforts and the financialand technical assistance provided by inter-national agencies. Each country should es-tablish its health priorities, according to itssocial and economic status and its own cul-tural and anthropological characteristics. Inthis way it will be possible to devote theresources available, both actual and poten-tial, to those health activities that meet thetrue needs and whose results will be themost effective. The existence of great andnumerous problems that must be urgentlysolved with limited resources is preciselythe drama and the challenge of the develop-ing countries and the factor that motivatedthe Alliance for Progress. In the circum-stances, it would be inadvisable to attemptto solve all of them at the same time. Forthis reason it should be scientifically deter-mined which problems are the most im-portant, which are capable of being solved,and on which the limited resources will havethe greatest effect. Such is the basic orienta-tion of Peru's public health policy, whichseeks to realize the aims of the national planfor economic and social development theGovernment has established.

The criteria preliminarily followed to

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determine the priorities under the objec-tives of Punta del Este are as follows:

1. The extent of the damage representedby the health problem;

2. Its social and economic importance, orimpact on social and economic development,and its place in our scale of cultural values;

3. The possibility of solving the problem,in terms of present conditions and the exist-ing fund of medical and public healthknowledge and techniques;

4. The cost of the activities needed toeliminate or control the damage representedby the health problem.

Seen from this viewpoint, Peru's prioritiesas regards the Hemisphere's main healthproblems, as set forth in the Charter ofPunta del Este, are as follows:, 1. Environmental sanitation deficiencies:

More than four fifths of the entire popula-tion, and 99 per cent of the rural population,lack drinking water services. Five sixths ofthe total population and practically all ofthe rural population likewise lack sewagedisposal services. Only 2 per cent of theworking population is protected againstoccupational hazards.

2. Malnutrition: The average diet in thecountry is deficient in calories, proteins,minerals, and vitamins. Large sectors of thepopulation are affected by nutritional dis-turbances and diseases.

3. High prevalence of communicable dis-eases, especially of the enteric type and thewater-borne communicable diseases.

4. High mortality in infants and pre-school children: Despite poor statisticalrecords, it is known that infant mortalityconstitutes one third of the country's totalmortality, and that deaths of children under5 years of age account for more than halfof the country's mortality.

5. Tuberculosis: The morbidity rates forthis disease are still high and the infectionis still widespread.

6. Malaria: More than 2,000 cases ofmalaria per year are still being recorded.

7. Smallpox: Although the disease hasbeen eradicated since 1954, the immunitylevel in 1962 was only 35.24 per cent of thesusceptible population, not counting thenon-immunized population in the immedi-ately preceding years.

The close link between the first fourhealth problems is obvious. Some are boththe cause and the effect of the others. Themeasures aimed at the control of some willpartially or completely control the others.From a purely pragmatic point of view,therefore, these four problems may be con-sidered as a complex that constitutes thehighest priority both for the entire Conti-nent and for each individual country.

The Ministry which I have the honor todirect is tackling these problems in thefollowing manner:

1. Negotiations are under way to financea basic rural sanitation plan, with the goalof providing drinking water to at least50 per cent of the rural population in 15years. The Institute of Occupational Healthwill extend its sphere of action to otherfields, including mining. It will be possibleto provide water supply and sewage dis-posal services to 70 per cent of the country'surban population through the Ministry ofPublic Works.

2. A study is under way to manufactureand market a local dietary supplementaimed at overcoming the more severe nu-tritional deficiencies. A national schoolnutrition plan is also under way.

3. An intensive program to improve localhealth services has been undertaken andwill provide better care for the pregnantmother and the child. This will be a mostimportant step toward reducing high infantmortality.

4. A national tuberculosis program is un-der way to make it possible to eliminate thedisease as a public health problem in threeyears.

5. The malaria eradication campaign be-gun in 1957 continues in operation and, on

Peru 89

the coast, either the maintenance phase hasbeen reached or the fifth year of total cover-age is being completed; in the jungle area,the fourth year of total coverage is eitherunder way or being completed.

6. In smallpox immunization, the aim isto reach the level of immunity needed tomaintain the eradication achieved eightyears ago.

The printed report which was distributedto the Ministers contains more detailed in-formation on all these problems and themeasures being taken to overcome them.

Although all these activities are no doubtof a positive nature, it must be recognizedthat it is possible, necessary, and even ur-gent to concentrate all efforts and resourceson the problems previously indicated, andto avoid dispersion of activities and makebetter use of existing facilities. Now that thepriorities have been established, it has be-come possible to do this. For the first timea national health policy has been drawn up;it is in keeping with the country's healthneeds, forms part of an integrated, conti-nent-wide action, and tries to keep in linewith the measures and objectives estab-lished at Punta del Este.

On this occasion I should like to reportbriefly on the main points of our healthpolicy, especially as it relates to the Alliancefor Progress.

A. General Remarks

1. If the spirit of the Act of Bogotá andof the Charter of Punta del Este, translatedinto the Alliance for Progress, consists in thecountries of the Americas making a commoneffort to achieve a better life for all in-habitants of the Hemisphere, and if thecommitment undertaken at the time lies indeveloping health programs to defend thehuman potential, then it is logical to as-sume that the national health policies mustto a certain degree be coordinated on ahemisphere-wide basis. This implies that

the countries must pool their efforts and re-sources on common problems, and that re-gional agencies directly or indirectly in-volved in public health must concentratetheir financial and technical aid on thoseproblems in a rational, planned, and co-ordinated manner.

In addition to the national health policy,a continent-wide policy will therefore haveto be formulated; it will have to serve asa general guide to national policies and con-tain a clear definition of the problems to beattacked and of specific feasible goals; andit must aim at activities planned and co-ordinated at the highest technical levels.

2. These national health plans should beintegrated within the broader national plansof economic and social development. Manyof the health problems have effective solu-tions which lie beyond the sphere of actionof health activities. Yet a national healthpolicy should be in harmony and compatiblewith the national development policy. Thelatter will necessarily limit the actions ofthe former, especially in cases where a de-veloping country is taking the initial stepsto promote its development. Internationaltechnical agencies should therefore givecareful and serious consideration to thisaspect in order to concentrate as muchtechnical advisory services and financial aidas possible on such special areas.

3. In each country's plan for achievingthe general objectives of the Charter ofPunta del Este full consideration should begiven to the needs for social development,especially in the areas of health, education,and housing, without, however, detractingfrom the resources and investments requiredfor the initial impulse toward development.So long as the effects of social investmentsare not quantified and expressed in terms oftheir contribution to economic productivity,it will not be possible to justify greater em-phasis on social development. Moreover, theintensification of scientific research, as re-ferred to in Title I, item 8, of the Charter,


should be basically oriented toward a meth-odology of social programming, and morespecifically, in our case, of health. Withinthis frame of reference, then, a nationalpolicy for solving the main health problemsshould be the result of a process of planningwhich arises from the confrontation of suchproblems with the facts of the local situa-tion and which is directed toward makingmaximum use of the resources available.

B. Most Important Measures

In the Ten-Year Public Health Programof the Alliance for Progress it is stated, ongood grounds, that to attain the objectivesof increased life expectancy at birth by atleast five years, certain measures will benecessary, such as:

1. Preparation of national health plansfor the decade.

2. Creation of planning and evaluationunits.

3. Improvement of collection and analy-sis of vital and health statistics.

4. Education and training of professionaland auxiliary health personnel, ascertain-ment of the number needed, expansion orcreation of training centers, and promotionof in-service training.

5. Improvement of the organization andadministration of health services at thenational and local levels by integratingpreventive and curative services and ensur-ing improved performance and better utili-zation of available technical knowledge.

6. Adoption of legal and institutional re-forms aimed at integrating health activitiesinto the economic and social projects.

The Government of Peru, through itsMinistry of Public Health and Social Wel-fare, has put into effect a system which willenable it to fulfill each of these measures.

In order to formulate and periodically ad-just the national health plan, a technical,advisory, and coordinating body is needed

to integrate the planning activities at alltimes and at all levels. Without discontinu-ing plans and projects already formulatedor under way, it was considered that thefirst step should consist in establishing aPlanning Office in the Health Ministrywhich could cover the health aspects inclose coordination with the national plan-ning agency charged with integrating thenational economic and social developmentplans. According to its purpose and func-tions, this Office will continuously formulatethe necessary recommendations for improv-ing the collection and analysis of vital andhealth statistics and the organization andadministration of the health services. Onlyin this way will it be possible to complytechnically with the measures recommendedin items 1, 2, 3, 5, and 6 of the Ten-YearPublic Health Program.

In order to train the personnel needed toexecute the national health plan, a TrainingCenter for Public Health Personnel hasbeen established; the Center's activities ap-pear in part 4 of Peru's report. The Plan-ning Office, in conjunction with the Schoolof Hygiene and Public Health of JohnsHopkins University, is conducting a surveyon human resources to determine personnelneeds. In this way Peru will be complyingwith the measure recommended in item 4 ofthe Ten-Year Program.

We are firmly convinced that only com-plete development planning-not restrictedto the national level but rather at the inter-national level, in which such social aspectsas public health are not overlooked-willmake it possible to achieve the objectives ona continent-wide scale and make the aspira-tions of the American peoples come true.

We are confident that the conclusionsreached and the recommendations made atthis important Meeting will make a positivecontribution to improving health conditionsand hence the level of living in our respec-tive countries.

ADDRESS BY THE MINISTER OF HEALTHOF BRAZIL

DR. PAULO PINHEIRO CHAGAS


The changes that are occurring in theLatin American scene are the reflection ofthe serious tensions which accompany thedevelopment process in our countries. LatinAmerica has the highest rate of populationgrowth in the world and a tremendous po-tential in its natural resources, yet it lacksthe capital and techniques with which todevelop them, and this circumstance, addedto its historical heritage, prevents it fromachieving progress at a more rapid pace.But in spite of these adverse conditions thepeoples of Latin America are anxious to im-prove their lot and to do so within theframework of this prodigious "revolution ofrising expectations" that is taking place,which makes the attainment of social well-being an imperative if the democratic sys-tem is to prevail, expand, and become con-solidated in our countries.

The idea of progress is the strongest mo-tivation of the Latin American people, whoare now claiming their fair share in the con-quests of modern science and technologythat have become available to mankind. Atthe present stage, economic developmenthas become the most effective means ofreaching levels of living commensurate withhuman dignity. This fascinating revelation,based on the historic examples of develop-ment in recent decades, has transformedinto a clamor the desire for progress of theimpatient masses of Latin America who areno longer content to await the hour ap-pointed by the slow clock of history.

In the realm of perspectives offered by

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economic development we learn two lessonsfrom the behavior of our people. The firstshows that the struggle for development isforced by a conglomerate of forces thatgovern the social processes of each of ourcountries; and the second reveals how im-perative it is that development respectnational values, with a minimum of infra-structure costs, and an equitable distribu-tion of development's benefits.

The anxieties and perplexities character-izing the panorama of the Latin Americanrevolution found in the Alliance for Prog-ress a vast estuary into which to dischargethe impetuous flow of our suffering but nolonger submissive peoples. The Charter ofPunta del Este, with its objectives toachieve a better way of life for all inhabi-tants of the Hemisphere, aims at reducingthe great difference between levels of livingin Latin American countries and in indus-trialized countries through accelerated eco-nomic and social development and con-tinued substantial increase of the per-capitaincome, as well as such structural reformsas will make it possible for the people toattain their just aspirations of improvingtheir living conditions.

The defense of the human potentialthrough the promotion of health programsto prevent disease and combat epidemics isamong the main points of the Charter,which embodies such principles as inspiredcommon agreement among the AmericanRepublics. The resolution that accompaniesthat basic document sets forth the Ten-


Year Public Health Program to be achievedthrough immediate and long-term measures.

Among the main recommendations is theone that health programs should be con-sidered and financed under the heading of"essential and supplementary" to economicprograms.

The main health objectives are: expan-sion of water supply and sewage disposalservices, reduction of infant mortality,eradication of malaria and smallpox, con-trol of the most prevalent communicablediseases, improvement in the diet and nutri-tion of the most vulnerable groups of thepopulation, and improved medical care forthe less privileged.

In establishing the principal objectives ofthe Alliance for Progress, the Latin Ameri-can countries agreed that it would be es-sential to development to achieve an annualper-capita economic growth of not less than2.5 per cent, the diversification of nationaleconomic structures, and the allocation oflarger portions of the national income toproductive investments.

The most interesting point in these am-bitious objectives is the concern for ensur-ing a fair share in the fruits of developmentto the peoples, through a redistribution ofthe national income so as to provide a betterliving standard for all. Starting from thepremise that the attainment of a better liv-ing standard rests mainly on a moderniza-tion of the economic system, and the ex-pansion of production through economic de-velopment, the countries of Latin Americain the Punta del Este Charter went onrecord to state that they were in favor ofan effective participation of the people inthe results of development through the ex-pansion of benefits arising from so called"social development." Development in-cludes health, education, healthful housing,clothing, employment, and recreation. Theattempt of some theoreticians to separatesocial development from economic develop-ment finds no support in historical analysis,

and can give rise to confusions and distor-tions that would damage the generous ulti-mate objective of development, namely, anincrease in the general level of living.

Other aspects of the program of the Al-liance for Progress deserve to be pointedout, for not to do so might lead to misun-derstandings or the untimely and dangeroussidetracking in the execution of programs.The commitment under the Alliance restson the conviction that: first, social, eco-nomic, and cultural reforms can come aboutonly through each country's "self-help" ef-forts, so that any outside assistance receivedis supplementary and auxiliary to the do-mestic effort; second, that development ac-tivities in our countries must be organizedin step with plans to mobilize national re-sources which, together with structural re-forms, will ensure a more equitable distri-bution of the benefits arising; third, that theestablishment of emergency programs ofstrategic scope and immediate execution, to-gether with social measures to decrease ex-isting tensions, are needed; and last, theexecution of programs will be multilateral,i.e., by mobilizing the joint efforts of allLatin American countries and the othercountries, within the framework of thespecialized agencies of the United Nations.

Twenty months have now elapsed since"Operation Alliance" was begun, and an ob-jective glance at the activities shows boththe difficulties encountered and the remediesneeded to increase its effectiveness.

The delay in applying the machinery fordetermining the activities required and theexcessive bureaucracy for their control isthe objection most frequently found, andthose in charge of executing the programare fully aware of this.

Lack of experience in planning, and theabsence of institutions that would permitthe Latin American countries to plan theirown economic development and put the ad-ministration of their public services in orderis another obstacle which only time and

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persistent effort will overcome. In thisregard, government agencies find it tremen-dously difficult to prepare technically ac-ceptable projects, which is a conditionrequired by the Alliance for obtaining finan-cial aid for specific programs. In some coun-tries this becomes an especially seriousproblem, since inflation prevents a realisticestimate of the expenditures that will berequired for a given project. To overcomethis obstacle in Brazil, the Ministry ofHealth decided to create a planning unitwhose purpose it is to remove such obstaclesby drawing up a national health plan ac-cording to recognized modern programmingtechniques.

The idea of self-help or internal efforts isnot well defined and therefore gives rise todoubts and mistaken notions as to its mean-ing and scope. Since external assistance is tobe marginal, due importance has to be givento the participation of the benefiting coun-tries. This includes considerations of a po-litical nature which need not be gone intoon this occasion. The proper and logicalattitude would be to derive inspiration fromthe principles of the Charter of Punta delEste, which aim at arousing national ener-gies in favor of development, in the aware-ness that they can do it "through applica-tion of the principle of self-determinationby the people," as set forth in the Declara-tion to the Peoples of America. According tothese directives, the most important effortswill have to come from the country whichbenefits from the program that is to be es-tablished, by an order of priorities to bedetermined by the conditions in each andaccording to the sovereign decision of eachindependent nation. The amount of the in-ternational aid should be fixed in globalterms, and the recipient country shouldhave the power to assign specific amountsto the various sectoral programs, followingthe basic criterion of promoting develop-ment to attain a better level of living forthe population. In this way, the criticism

of "welfare" levelled at the Alliance couldbe avoided, a criticism that is justified tothe extent to which a program to promoteconsumer activities is imposed from the"outside," to the detriment of productive in-vestments which could be more effective inpromoting development. This reversal of theorder of priorities-as suggested by someprojects which attempt to point up themerits of the wealthy countries-empha-sizes the "demonstration effect," aggravatessocial tensions, and retards development, allof which is detrimental to the objectiveshoped for by those who formulated theAlliance for Progress.

The substitution of the multilateral con-cept for a bilateral program is anothersource of difficulty in carrying out the Al-liance for Progress. In preventing a newexperience in cooperation among LatinAmerican countries, in doing away with thecollaboration of other developed countriestoward promoting the development of theless developed ones, and in exchanging plan-ning efforts for a casuistic discussion whichmakes it impossible to look at nationalproblems from an over-all view of develop-ment, the bilateral operations place a tre-mendous burden on the United States ofAmerica, which is faced with the possibilityof such programs failing and the naturalresistance provoked by the suspicion thatthe offer of assistance is of the nature oftutelage and that standards for solving theproblems of beneficiary countries are beingimposed on them.

If on the one hand foreign aid couldpossibly be considered an instrument forimposing plans unsuitable for the develop-ment of Latin American countries, then onthe other hand, it becomes necessary towarn against the danger of paralyzing thefighting spirit of our people should theycome to believe that progress can be ob-tained through the generosity of the wealthycountries.

These are some of the obstacles to execut-


ing the Alliance for Progress programs; theymust be removed to smooth the road ahead.

The health function in economic develop-ment programs is beginning to be properlydefined, bearing in mind the need to ensurean increase in real per-capita income, whichis their objective.

The fact that the developed countrieshave a high level of health owing to thewealth produced by the country and to thesharing of it by diverse population groups,has led to the belief that such levels can beattained exclusively through an expansionof the health care system, and the exclusiveuse of health techniques. This fallacy led tothe adoption of unrealistic plans for solvingthe health problems of developing countriesand to the automatic use of transplantedprograms, which is also a fallacy.

A study of the process of economic de-velopment and the stage at which eachcountry finds itself is a basic prerequisiteto the formulation of suitable plans, whichmust be adjusted to the social and economicsituation of the country and to its structureand organization.

The developing countries have their ownnosology, a peculiar complex of resources,and a series of health problems linked topoverty and backwardness, which thereforerequire different solutions and programssuitable to their underdeveloped condition.

Formulas for meeting the needs with theavailable resources, determination of priori-ties, relationship between costs and benefits,contributions to programs for increased pro-duction, all are useful in drawing up healthplans. Finally, the health policy must beintegrated into the general economic de-velopment plan so that health may becomea dynamic element in its execution. Becauseof this it will be advisable to prepare healthplans that are subordinated to the directivesof the general economic and social develop-ment plan, once the perfect compatibility ofthe objectives of both has been assured.

This is the main idea which inspired the

recent Three-Year Plan for Economic andSocial Development established by the Gov-ernment of President Joáo Goulart. Thedevelopment policy set forth in this Planpursues the following objectives:

1. To ensure a rate of growth of the na-tional income commensurate with the Bra-zilian people's aspiration to better livingconditions;

2. To gradually reduce inflationary pres-sure so that the nation's economy may re-gain a suitably stable level of prices;

3. To achieve a more equitable distribu-tion of the fruits of development by raisingthe people's real income;

4. To intensify government activities inresearch and training;

5. To reduce regional disparities by in-creasingly using the natural resources avail-able and by reorienting the location ofeconomic activities;

6. To eliminate institutional obstacles toreorganization so that productive factorsmay be used to better advantage and newtechniques may be assimilated;

7. To attempt to refinance the externaldebt and to reduce the deficit in the 'balanceof payments; and

8. To introduce suitable planning meth-ods in the administrative activities of thegovernment agencies.

The Three-Year Plan includes general di-rectives on economic policy and standardsfor the various administrative sectors, in-cluding health.

On the basis of recognized improvementin the past two decades in the Brazilianpeople's general health conditions as a re-sult of the process of industrialization, theThree-Year Plan establishes guidelines forthe policy to be followed to ensure furtheradvances in this regard.

In the plans prepared for health care,special consideration was given to cost ofprograms, number of population benefited,and target dates. Among the general princi-ples of Brazil's new health policy special

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emphasis was placed on protecting the com-munities from communicable diseases, andon the prevention and cure of major en-demic diseases which affect large sectors ofthe rural population. Such supplementarymeasures as nutrition, basic environmentalsanitation, housing, and the creation of newjobs are expected to exert a decisive influ-ence in the campaign against diseases pre-vailing among large population masses whomigrate from the rural areas to the cities.

A study of resources available for carepurposes shows the increasing expansion ofthe existing network of services, which arecharacterized by low output, poor utiliza-tion of resources, and general waste. Thereis great concern over having sufficient per-sonnel available, since most services tend tobe concentrated in the large urban centers.

Some of the measures contained in theThree-Year Plan are as follows:

a. Decentralization of health activitiesand their transfer to municipalities;

b. Expanded assistance in providingpharmaceuticals, together with intensifieddrug production by official laboratories;

c. Promotion of private medical careagencies by assistance to enable them toperform supplementary care activities forthe underprivileged classes;

d. Coordination with social security agen-cies to increase the benefits provided andreduce costs;

e. Promotion of medical care programsfor rural inhabitants by using the healthand hospital units in the interior of thecountry;

f. Improvement of the existing hospitalnetwork and of its administrative methodswith a view to increasing performance andreducing maintenance costs;

g. Improvement of the system for thecollection of statistics in order to providebetter evaluation of programs;

h. Support of maternal and child healthprojects by furnishing nutritional supple-ments for vulnerable groups;

i. Reorganization of the Ministry ofHealth and establishment of guidelines gov-erning the preparation, coordination, execu-tion, and evaluation of health programs.

As to the financing of health programs,the Three-Year Plan provides for a sub-stantial increase in public services, i.e., from1.4 per cent of the gross national product in1960 to 1.8 per cent in the current year. Inthis year's federal budget 42 per cent of thefunds allocated to health are earmarked forwater supply and sewage disposal systems,which is indicative of the high priorityaccorded to this public service.

The poor health conditions of the Bra-zilian people are reflected in low levels ofliving which are the consequence of under-development. Communicable diseases havebeen virtually eradicated from our noso-logical picture. But the diseases that affectlarge sections of the population are thosethat constitute the nub of the problem. Theyinclude the rural endemic diseases thatafflict the poor sectors of the population.

Leprosy, yaws, trachoma, tuberculosis,filariasis, Chagas' disease, hookworm dis-ease, and leishmaniasis are being energeti-cally combated, and results are already evi-dent in the clear regression of the first twodiseases. Malaria and schistosomiasis arenow the two diseases that call for majorefforts. As for malaria, epidemiological sur-veys made in the Amazon region revealed achange in the prevalence of Plasmodiumspecies, there being a high percentage ofP. falciparum with highly virulent strainsresistant to schizonticides. And as for schis-tosomiasis, because of the complexity of itsclinical manifestations, the great damage itcauses, and the fact that it is spread overvast areas of the country, it is a diseasewhich represents a great challenge to bothmedical and health agencies. Some of thesteps being taken against the disease are theuse of effective molluscacides to destroy theintermediate host, and health educationaimed at changing the habits that result in


water contamination and the expansion ofenvironmental sanitation services.

The expanded water supply and sewagedisposal program is receiving the attentionit merits because of its importance in im-proving the health conditions of the people.The high cost of the installations, the limi-tations on charging water rates because ofthe low per-capita income, and the inabilityto maintain existing systems, have led to theestablishment of priorities for selecting thelocation of projects according to populationdensity and their ability to absorb thecorresponding investments.

As to nutrition, the Government of Brazilis attempting to correct by suitable meas-ures the more severe food deficiencies, par-ticularly those of animal protein. The pro-duction of other sources of protein, such asfish, chickens, and milk, is being encouragedand supported by government agencies.

In order to train the personnel needed to

intensify the program, measures of greatscope must be adopted and these are beingexamined within the framework of the basicreforms now being undertaken in Brazil.

Finally, activities aimed at reducing highinfant mortality rates are being included inthe campaigns against underdevelopmentand backwardness. The aim is to preventpremature deaths in children, and to helpthem grow up and live so that they maycooperate in building the new and pro-gressive country which Brazil wishes to be.

This is the message I bring to this Meet-ing as a token of Brazil's fraternal feelingstoward the sister republics in all America.On behalf of the Delegation of Brazil, I ex-press the hope that this Meeting will becrowned with success, and I salute the dis-tinguished representatives of the Americannations and of the sponsoring agencies, whoare gathered here to work for the progressand welfare of our peoples.

ADDRESS BY THE MINISTER OF PUBLIC HEALTHOF CHILE

MR. BENJAMIN CID


I bring you cordial greetings from theGovernment of my country,the Governmentof President Jorge Alessandri Rodríguez.

In formulating a health policy, considera-tion must be given to the multiple aspectsof such a complex problem.

Health is, in the first instance, a technicaland administrative problem. We have inChile the National Health Service, on whicha 67-page pamphlet has been distributed tothe representatives, giving all the necessaryinformation. In addition, we have the pri-vate employees' medical service, the work-men's accident fund, and private hospitalsand clinics.

In order to provide the best possiblehealth care with the human and materialresources available, we have since 1952 in-tegrated medical care services with healthpromotion and protection services, withinthe National Health Service. In the courseof the last eight years there has been an in-crease of 1,442,000 in the number of personsbenefited (or 27.3 per cent).

A Hospital Construction Association wasestablished in August 1945, and from thatyear to 1958 it built 30 hospitals with acapacity of 5,438 beds and covering a sur-face area of 179,496 m2. During the presentadministration, the Association has built 31hospitals, with a capacity of 1,772 beds andcovering 77,462 m2 . In addition, 58 hospitalswith 3,885 beds and covering 193,356 m2 areunder construction. The country therefore

has a total of 119 hospital establishments,with 11,095 beds, in an area measuring450,314 m2, which makes an average of morethan 90 beds and 3,784 m2 per hospital.

I take this opportunity to thank the Gov-ernment of the United States of America forthe generous assistance given to us in thearea devastated by earthquakes.

A study of the principal causes of deathshows that the very origin of risks of illnessand death is to be found in causes which arenot strictly medical. These relate to theshortage of healthful housing, lack of en-vironmental sanitation, and a national foodproduction rate that does not keep pace withthe population growth. For this reason at-tention is being given to housing construc-tion and agrarian reform, a fact of which weare justly proud.

Health is also an educational problem.Chile has come to realize that in order tofulfill its health plans and objectives thequantity and quality of its technical andadministrative personnel will have to beimproved. Therefore, a National TripartiteCommission was established, composed ofrepresentatives of the National HealthService, the Schools of Medicine, and theMedical Association, to take maximum ad-vantage of existing resources with which toovercome the shortage of professional per-sonnel. This Commission will plan medicaleducation and training after making studiesof: personnel resources; demographic, eco-nomic, and educational characteristics;

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trends and scope of demands for medicaland health care by the population; andmedical work output and its increasethrough good administrative practices.

In addition to this joint endeavor, atten-tion is also being given to the education andtraining of recent graduate physicians bymeans of residency fellowships and posi-tions in which general practitioners from thezones can be trained or in which training inthe most needed specialties can be given.The problem is not only one of medical andpersonnel training, but one of general edu-cation. Owing to the population's greaterknowledge about public health, its increasedawareness of its legal rights, and its con-cern for health care, the demand for servicesis constantly increasing and has reached thepoint where it can no longer be satisfiedwith the present human and material re-sources.

Health is also a matter of research pro-grams, of planning, and of methods. Re-search is being carried out on various healthproblems, either in institutions attached tothe Ministry of Health or in conjunctionwith other institutions under the Ministriesof Education, Economy, and Agriculture. Inthis way studies have been undertaken onvarious diseases, on nutrition, and on plan-ning methodology.

It has become apparent that the specifichealth problems to be solved are as urgentas they are varied. It has also become evi-dent that in many instances the solutionlies beyond the sphere of medicine or publichealth and calls for the efforts in such otherfields as education, agriculture, and housing.The resources with which to carry out theseactivities are limited and have to cover thegoals established in other fields of economicand social development as well. This factmakes the need for establishing prioritiesall the more urgent and calls for a maximumefficiency in the operation. Hence the needfor preparing health plans which subse-

quently must be integrated with the socialand economic development plans.

We have a complex task ahead of us. Thetechnique of planning, still a relatively newone, arose out of the concern over problemsof economic development. Its application tohealth requires considerable adjustment ifthere is to be achieved an effective meth-odology that will make it possible to prepareand execute realistic plans for mutuallycompatible goals with the kind and amountof resources available.

This consideration becomes the more im-portant if one bears in mind that planningdoes not mean merely drawing up a docu-ment which establishes certain objectives tobe achieved by a given time and at anapproximately estimated cost. Planningmust rather be understood as a continuousprocess with stages of diagnosis, prognosis,and programming as such, and discussionand decision at the policy level must befollowed by execution, evaluation of results,and revision of initial goals, so that the ob-jectives will be attained through adjust-ments to varying circumstances. When aGeneral Plan of Economic and Social De-velopment is approved, it contains a chaptercalled the Health Plan. It must be borne inmind that the community is making a choicebetween alternatives and in so doing it un-avoidably formulates value judgments. Wewho know the priority of the health prob-lems have the duty to explain the objectivesin our area with the utmost clarity andprecision, so that they may be given dueconsideration in the General Plan.

We therefore believe that this conference,which will echo the studies already begunon this matter in well-known research in-stitutions, must give special attention tofinding a concrete and practical method-ology for health planning, and to the ob-stacles to its efficient use in our countries.

I should like to express thanks for theadvisory services we have received from thePan American Sanitary Bureau, which is

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under the direction of my good friend Dr.Abraham Horwitz. Please accept the goodwishes of the Minister of Health of Chile.

It is further evident that health is aneconomic and financial problem, in additionto being a human problem. Chile's NationalHealth Service has provided milk to 70 percent of the nursing babies, wet nurses, andpregnant women of the country, and to alesser proportion of preschool-age children.

But health is also a cultural problem. Theunity of our culture brings to mind thelessons of old colonial history. The ships ofthe fleet which carried treasures to Spainhad to sail in plain sight of each other so asto watch each other and protect themselvesfrom pirates and corsairs. The sailors knewfrom experience that the speed of the entirefleet depended on the speed of its slowestvessel.

Today more than ever, because of the

unity of our culture, our countries mustnavigate in plain sight of each other. Thatis the direction of the Alliance for Progress.It is so understood by all our Governments,that of my country, the Government ofPresident Jorge Alessandri Rodríguez, andby the Government of the United Statesof America, that of President John F.Kennedy. Let not the vessel that sails mostslowly fall into the hands of pirates andcorsairs.

Health is also a legal problem. At itshighest level, the right to health should beguaranteed in the constitution. Health andeducation should be added to the classicprinciples of liberty, equality, and frater-nity.

A free democracy is possible only withinan Alliance for Progress based on healthand education. Thus will true fraternityreign among men and peoples.

ADDRESS BY THE DIRECTOR OF THE NATIONAL PUBLICHEALTH SERVICE OF BOLIVIA

DR. FRANCISCO TORRES BRACAMONTE


In expressing regret at the absence of theMinister of Public Health of my country,who was unable to come to the Meeting, Ishould like first to extend cordial greetingsto the distinguished representatives of oursister republics, and to state our thanks tothe Pan American Health Organization forhaving made this event possible, and to theUnited States of America for the fine hos-pitality being offered to us.

Bolivia's public health problems havebeen presented simply, realistically, andsincerely in the text of the two-year planthat has been distributed to all, and whichforms part of the ten-year health plan ofmy country.

I shall not present even a summary, whichwould necessarily be incomplete, but ratherlimit myself to some general aspects.

At the conference held in October 1941in Atlantic City, New Jersey, and in Wash-ington, D.C., the leaders of Pan Americanhealth signed a document that was to cometo be known as the "biological defense" ofthe Hemisphere.

I must state that the document arose outof conversations among representatives ofsmall countries to obtain effective aid fromstronger nations. We stated the need forconsidering the Hemisphere as a living en-tity. As in the human body when one organis sick and cannot function and developnormally, we stated that the Hemispherecould not fulfill its destiny so long as therewere underdeveloped regions. From this wasdeduced the imperative need to help coun-

tries that had not yet developed sufficientlyto protect the health and welfare of theirpopulation.

The United States of America, aware ofits responsibility as the leading nation, afterthe approval of Resolution XXX in Janu-ary 1942 at the Meeting of Ministers ofForeign Affairs in Rio de Janeiro, entrustedthe Department of State with the establish-ment of an agency called the Institute ofInter-American Affairs, which in turn or-ganized cooperative services in 18 LatinAmerican countries.

The World Health Organization has de-fined health as a state of complete physical,mental, and social well-being, and not onlythe absence of disease or infirmity.

The Director of the Pan American Sani-tary Bureau has mentioned mental healthamong the objectives planned for the pres-ent decade.

In the December 1943 issue of the Boletinof PASB,* which was devoted to Pan Ameri-can Health Day, there is the followingstatement which we made: "While it is truethat destiny is the automatic outcome ofpast causes, it is no less true that the in-complete education of a child is the es-sential origin of wars.... We must pro-tect the children from evil thoughts as weprotect them from contagious diseases. Atthe present time, therefore, there is nothingmore important than to form the forces thatwill mold the future generations."

*Boletín de la Oficina Sanitaria Panamericana,Vol. XXII, No. 12 (December 1943), p. 1060.

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Bolivia 101

Today, 20 years later, we are convincedthat it is even more important to protectthe children of this Hemisphere from evilthoughts. It is therefore necessary to pre-pare a program for the ideological defenseof the Americas.

Psychological errors, tension, conflict,anxiety, maladjustment, produce far greaterevils than do organic diseases, many ofwhich are nothing more than the physicalexpression of such nervous states.

We attempt to change the world throughmore or less systematized ideologies, and weforget that we are the ones who create so-ciety, and that order or confusion will existdepending on how we live.

Our everyday thoughts, feelings, and actsmust exert an influence on our environment;the world, therefore, is what we are; henceour problem is the problem of the world.The practical application of this concept ismarvelous in its simplicity.

We cannot solve the problems of theworld by looking toward Washington orMoscow. More important than any ideologyis the transformation of the individual, andthis transformation is possible only in anenvironment of freedom.

To understand the complex problem oflife with its pains and conflicts there must becomplete comprehension leading to full ac-tion. So long as we do not solve the problemof individual relationships, we shall not beable to solve the social problem, becausesociety is nothing more than the extensionof the thoughts, feelings, and actions of theindividual.

If we could have the gift of fully under-standing our relationship to things, persons,and ideas, we would not find it difficult toenjoy the beauty of a simple life. We wouldagain become like children. In children thefeeling of fraternity is natural. Children ofdifferent races and social strata can playtogether, completely unaware of differences.

The wisest teaching for humanity con-tinues to be the maxim inscribed on thefront of the temple of Apollo at Delphi:gnothi seauton (know thyself).

The leaders of nations should fully under-stand their responsibility in this hour andshould endeavor to offer to coming genera-tions the opportunity to enjoy a healthybody, a noble heart, and a clear mind, soas to make the advent of an era of frater-nity possible, an era in which justice andpeace will reign in the world.

ADDRESS BY THE MINISTER OF PUBLIC HEALTHAND SOCIAL WELFARE OF PARAGUAY

DR. DIONISIO GONZALEZ TORRES


I should like to express the great pleasurewith which my country is participating atthis Meeting, from which we all hope to ob-tain the best results for the good of ourpeoples. We are aware of its importance, ofthe magnitude of the problems to be dis-cussed, and we are each prepared to con-tribute the best that is in us toward thiscommon effort.

Activities aimed at the progress and themore rapid development of our peoples areoccurring in rapid succession, and they areindicative of the urgent need for meetingthe just needs of human beings who areasking for a better, more meaningful, andlonger life.

In August 1958 President Juscelino Ku-bitschek of Brazil launched the idea of"Operation Pan-America," which calledupon the countries of the Americas to study,in mutual consultation, the problems thatimpede their development and to formulatesuitable measures of economic cooperation.

In September 1960 the American coun-tries signed the Act of Bogotá, which madeprovision for measures to improve theirsocial and economic development.

Other meetings and declarations fol-lowed. In March 1961 President John F.Kennedy made his first declaration on theAlliance for Progress, to the effect that theUnited States of America would allocatefunds to promote Latin American progressand development.

August 1961 saw the establishment of theCharter of Punta del Este, which outlined

an action program and contained a defini-tion of the philosophy of the Alliance,established the objectives and basic require-ments for attaining development in theeconomic, social, educational, and publichealth fields, and also indicated the needfor immediate action. It further containedthe recommendation to the Governmentsand peoples of the Americas to resort toself-help, plan their programs, undertaketax and other reforms, attempt to achieve amore equitable distribution of the taxburden, a stabilized currency, balancedbudget, better land distribution and use,fuller utilization of sources of production,planned resettlement, and so forth.

Also in August 1961 we Ministers ofHealth of Argentina, Brazil, Paraguay, andUruguay met in Iguazú, Argentina, to dis-cuss our common health problems.

However, before the Alliance for Prog-ress, the Government of Paraguay was al-ready instituting many of the recommenda-tions made in that inter-American pact.

In fact, Operation Pan-America beganto be practiced by Paraguay and Brazilaround 1955, when the two Governmentsand their peoples joined efforts in buildingthe road that leads from Asunción to theParaná River, over which rises the monu-mental bridge linking that road with Pa-raná State and leading to the AtlanticOcean, thereby opening up new opportuni-ties to settlers and affording new prospectsof progress to the two sister nations.

I shall not go into detail about our health

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problems, which will be discussed morebroadly in our committee meetings, but Ishould like to outline what the people andthe Government of Paraguay have done infulfillment of the recommendations of theAlliance for Progress.

Basic activities in the economy and fi-nancial infrastructure of the country arebeing planned and undertaken; foreigncapital is flowing in, the established enter-prises are being expanded, industrial plantsare being modernized, and new industriesare being created; the finances of the Stateare being put in order without inflation oran unbalanced budget, with a stable cur-rency, and there is regular payment of thesalaries of civil servants and regular fund-ing of the public debt and of internationalfinancial commitments. Important publicworks are being carried out. There are morethan 2,000 kilometers of roads that unite uswith Brazil, Argentina, and Bolivia. Themore important highways are being coveredwith asphalt, and landing fields, airports,bridges, barracks, schools, and health postsand centers are being constructed. There isalso a new merchant marine fleet with some30 boats. As to social and cultural works,there are schools, colleges, and universitydepartments, with modern university stat-utes; there is equitable and planned landdistribution, without bloody revolts occur-ring or anyone being deprived of his landholdings; land settlement is organized,working conditions are improved, and thereis protection for the worker and his family.In the legal and spiritual realm, civil andpolitical rights have been granted to women,and there is protection of the child, theelderly, and the needy. Our legal codes havebeen modernized and others that did notexist before have 'been drawn up. Ourartistic heritage is protected; better condi-tions have been provided for our artists andtheir work.

In Paraguay there is a legality whichprovides full constitutional guarantees to

the citizen without distinetion or discrimi-nation, and which governs the legal rela-tions between the citizens of the Republic,between government institutions and agen-cies, and between the State authorities. Inthe international field, Paraguay fulfills itscommitments, as evidenced by its clear lineof conduct during the past decade. It is anation respected by other free nations be-cause of its firm anti-Communist attitude,without giving way to fears, because of itssolidarity and friendship with neighboringcountries and the higher interests of all theAmericas, and because of its position in theline of defense of Christian and Westerncivilization and its respect for the policy ofnon-intervention in the internal affairs offriendly nations. Peace has been achieved,and law and order reign in the Republic.Peace was defended decisively and at thecost of sacrifices against those who wishedto sow discord and chaos in our land. TheGovernment and the republican party havedefinitively consolidated and improved ourrepublican democracy.

We mention these facts to show the gi-gantic efforts made by the Government andthe people of Paraguay, which had to do allthis in less than 10 years, because every-thing needed to be done.

As to self-help, we have been practicingit for some time. All that has been done sofar we achieved without overburdening thecountry with debt, since up to 67 per centof the costs are being covered with our laborand the remaining 33 per cent with foreignloans, which are now being repaid. In manyinstances these loans were granted to us ona purely commercial banking basis, withoutbearing in mind the reality of the problemsto be solved; but the contributions of thecommunities have been very important, inmany places exceeding those of the Govern-ment, and these were in cash or in labor orin local materials and helped the Govern-ment to solve the problems of the popu-lation.


But the enormous efforts of these fewshort years have taken their toll and pre-vent us from achieving more rapid develop-ment, and despite the fact that theParaguayan Government understands theimportance of our health problems and thepriority they require, it has not been pos-sible to increase the funds allocated to theHealth Ministry, which for years have been6 per cent of the national budget.

In this regard I should mention some-thing Dr. Horwitz already wrote about,namely, the economic cycle of disease-orthe economic factors and their bearing onhealth. A serious problem not only in ourcountry but in many Latin American coun-tries, which merits special attention by theeconomic experts of the Alliance for Prog-ress, is the fall in prices on the internationalmarket of the raw materials we export.

From this viewpoint Paraguay lost 87million dollars of income in eight years, orsome 11 million dollars per year, whichrepresents 35 per cent of its total foreignexchange from exports in a given period. In1952 we used to receive $122 per ton ex-ported, by 1957 only $103.80, and by 1962only $95.50-all for the same products-and that is a great loss for a developingcountry.

A study recently made by Dr. LlerasCamargo showed that the fall in prices onthe world market in coffee, saltpeter, cop-per, fruit, meat, and so forth, meant a lossto Latin America of thousands of millionsof dollars in the last 15 years.

The truth of the matter is that interna-tional monopolies have deprived us ofcapital; today we must work and producemore to obtain about the same amount ofdollars as we did 10 years ago, yet we mustpay increasingly more for the industrialproducts we buy. This tends to impoverishus more each time, with all the consequencesthis brings for progress and well-being,which stagnate or register at most only avery slow advance.

It is also true that we would not haveneeded to request so much from the Alliancefor Progress had we received suitable pricesfor our raw materials and products. Thisis a matter which deserves to be studied bythe economic experts with a view to findingan appropriate solution.

After the Act of Bogotá, in April 1961,Paraguay presented a four-year plan ofpublic health to the Agency for Interna-tional Development, some aspects of whichare now being implemented.

As to planning, during and shortly afterthe Meeting at Punta del Este the impres-sion clearly was that planning should con-sist of two stages: short-term planning andthe long-term planning-at that time therewas talk of a ten-year plan. Paraguaytherefore presented a short-term plan andrequested additional contributions for en-vironmental sanitation (provision of watersupply to 10 rural communities); for com-pletion and remodeling of health centers,with provision of equipment, materials andinstruments, especially in newly settledareas; and also for domiciliary child care,health education, personnel training, andmalaria eradication, amounting all togetherto three and a half million dollars.

Studies for long-range programs, the ten-year public health program, were and arestill being made. The Government set upthe Bureau of National Planning attachedto the Executive Branch, as well as a Minis-try for Ministerial Committees, working incoordination.

The Planning Committee of the Ministryof Public Health has promoted meetings ofthe heads of health regions and of medicalcare centers to prepare the ten-year publichealth program.

I should like to report something veryimportant to us and indicative of the extentof the assistance Paraguay has receivedfrom the international agencies. For thepast two years, before the Alliance forProgress, we have been planning at several

Paraguay 105

levels in our country, at first with financialassistance from the United States of Amer-ica, through the Inter-American Coopera-tive Public Health Service, and later withthe assistance of PASB/WHO, UNICEF,and FAO.

Since 1957 our administration has beenprogressively decentralized through the in-tegration of the programs in health centers,according to a five-year plan. In the courseof eight or nine years we have sent 60 publichealth workers and technicians for trainingabroad through fellowships from the agen-cies mentioned. All top-level posts and 70per cent of the posts in health centers arenow filled by trained public health workers.

While we were waiting for a reply on theshort-term plans presented to the Alliance,and while ten-year plans were being drawnup, we continued to carry out programs andto expand others, with assistance from theabove-mentioned international agencies, inthe following fields:

1. Environmental sanitation: This activ-ity has been given high priority and impor-tance, as we have running water supply andsewage disposal systems only in the capital.With the cooperation of the Agency for In-ternational Development, a pilot plan wasestablished for providing drinking waterservice to three rural localities, later to beextended to 10. The engineering office forthis project is now being installed and thefirst survey of water sources is being made.The socioeconomic study of the commu-nities to be benefited has already beencompleted.

2. Food and nutrition education: A tri-ministerial plan (Ministries of Education,Health, and Agriculture) has been expandedfrom 80 to 140 localities since last year. Thepurpose is to promote the production ofbasic foods, establish school and communityfarms and gardens, foster reforestation andthe planting of fruit trees, provide healtheducation, and distribute powdered milk tothe most vulnerable population groups.

3. Communicable diseases: These con-tinue to represent an important problem,being among the principal causes of highmorbidity and mortality, especially in chil-dren and young adults. The picture has notchanged substantially in the last five years,except for smallpox, of which no autoch-thonous case has occurred for the past threeyears.

A pilot plan for communicable diseasecontrol in the capital and neighboring areashas been prepared by national personneltrained by UNICEF and PASB/WHO staff,and has been submitted to UNICEF.

4. Malaria: Epidemiological surveys arebeing completed this year, as is the pilotplan of geographic reconnaissance and thehouse census, etc. The malarious area coversthe entire national territory and, contraryto the original belief, Anopheles darlingi isautochthonous in the main sector becausedieldrin did not succeed in interruptingtransmission. A twice-yearly cycle of DDTsprayings is being planned instead of thepresent single annual dieldrin spraying.

Despite slight increases in the contribu-tions of the Government and of UNICEF,the funds did not suffice and additionalfunds had to be requested from the Alliance.

5. Vital statistics: These data are im-proving, the'reporting area having been ex-panded through changes introduced in theStatistics Department on the advice ofa WHO expert. Statisticians have beentrained both in the country and abroad.

6. Medical care services: In the capital,these services are being centralized by theHealth Ministry so as to economize onpersonnel and materials, with benefits thatare already noticeable.

7. Studies and agreements with other in-stitutions providing medical care are beingmade by the Ministry to prevent duplica-tion of efforts.

8. With the aid of the U.S. Agency forInternational Development and the W. K.Kellogg Foundation, the Ministry com-


pleted the installation of a plant for theproduction of drugs for use in the healthcenters. This has resulted in a great savingsin costs.

9. The Ministry of Public Health alsocooperates in the plans of the Ministry ofEducation for resettlement and rural wel-fare.

10. International contributions for theschools of nursing, obstetrics, and socialservice of the Ministry were extended andincreased.

I state these facts only to show that, whilea reply on the plans presented to the Alli-ance is being awaited, Paraguay is proceed-ing to carry out its programs, to do what itcan, although much remains to be done thatwill require additional contributions fromthe Alliance. For it would take the countryfar longer to do all this with its own re-sources and the work would not keep pacewith the natural growth of the population.I state these facts, above all, to acknowledgethe valuable contribution in the form offellowships, technical advisory services, ma-terials, and equipment that we have re-ceived and continue to receive from theU.S. Agency for International Develop-ment, the Inter-American Cooperative Pub-

lic Health Service (SCISP), PASB/WHO,UNICEF, FAO, the W. K. Kellogg Founda-tion, the University of Buffalo, and so forth.For this we wish publicly to thank thesebodies on behalf of the Government and thepeople of Paraguay, and also to point outthe need for the Alliance to take advantageof the long experience of these internationalagencies in planning and execution.

I believe that our purpose here is tostudy and propose practical measures withwhich to carry out the plans of the Charterof Punta del Este in the matter of health,and to prepare the inhabitant of LatinAmerica, who is the object, the means, andthe end of well-being and progress of ourpeoples, the foundation of the welfare towhich we all aspire and are entitled.

We once more have before us new hopeswhose attainment depends on us. The par-ticipants from Paraguay at this Meetingtrust that we shall be able to revise theprocedures so as to simplify slow-movingnegotiations, see to it that our peoples arenot disappointed, and faithfully interpretthe thoughts of the great leader of thedemocratic world, President Kennedy. Inthat way we shall create a healthy andvigorous America that will fulfill its greatdestiny.

ADDRESS BY THE REPRESENTATIVE OF THE MINISTER OF PUBLICHEALTH AND SOCIAL WELFARE OF GUATEMALA

DR. ROBERTO ARROYAVE


In the matter of health, Guatemala as-pires to the ideal expressed in the words:health is a state of complete physical, men-tal, and social well-being of an individual ora people.

In view of this basic, but also noble andambitious objective, the what, how much,and where of immediate objectives comes tomind, as do the means by which to attainthem. Guatemala is deeply concerned abouthealth problems.

If one compares Guatemala with an in-dustrialized country, it is clear that its eco-nomic and social development is only justbeginning, and that good health conditionsare enjoyed by but a few. The rest of thepopulation do not enjoy these benefits, andthis fact is aggravated by food shortages,poor quality foodstuffs, lack of financialmeans, and in sum, the absence of a suitableenvironment for every Guatemalan to beable to live happily.

High morbidity and mortality rates thatstill prevail in my country are the outcomeof 400 years of living under poverty con-ditions, malnutrition, poor environmentalsanitation, lack of health education, andinsufficient health services to provide medi-cal care and prevent disease.

Guatemala has conducted programsagainst certain diseases with varying re-sults, which are always attributable to thefollowing factors: (a) financial limitations;and (b) limitation on the number and train-ing of medical and technical personnel with

which to conduct the necessary health cam-paigns.

Nevertheless, technical and financial as-sistance from international agencies, addedto the country's own efforts, have made itpossible to eradicate typhus, yellow fever,smallpox (last case in 1953), and to conductcampaigns against malaria, malnutrition,gastroenteritis, whooping cough, and otherdiseases. All this was done at the nationallevel, while we believe that it should bedone at a higher level, so that a pooling ofthe resources will protect a greater area.

To this end, Guatemala has decided toconcentrate its efforts on campaigns thatare of equal interest to all six countries ofthe Central American isthmus, which havea similar geography, history, and economyand are the target of the same scourges.

We have numerous health problems, butexisting limitations have forced us to accordpriority to only some, although we are wellaware of the importance of the others whichwill also gradually be attended to.

For this reason I shall refer to only fourpoints which we consider basic for attaininga suitable environment for our people tolive happily.

Since the purpose of this important Meet-ing is to prepare recommendations whichwill favor the health climate of America, Itrust that by putting aside narrowly con-ceived nationalisms we shall be able tobroach the solution to our problems froma solid foundation, the outcome of well-documented studies that are adjusted to the

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environmental and economic realities of ourcountries.

Guatemala's general mortality index is16.3 per cent, and the age group most af-fected is that under five years, which ac-counts for 49.3 per cent of the general mor-tality.

The country's poor environmental andhealth conditions make the 10 principalcauses of morbidity and mortality thosevery diseases that can be controlled byhealth activities.

I. MALARIA

Even before 1955 there was a malariacontrol service attached to the PublicHealth Service in Guatemala, which wasprimarily engaged in the application ofantimalaria drugs.

The Malaria Eradication Service was es-tablished on 10 January 1955; technicalknowledge of the problem showed that erad-ication was feasible if residual insecticideswere used. A Malaria Eradication Law wasdrawn up in July of the following year, withthe technical advice of PASB/WHO; it wasdrafted in sufficiently flexible terms to allowany problems arising during the campaignto be solved.

The results have been encouraging. Be-fore the campaign, the average number ofmalaria patients was 300,000 a year, ac-cording to hospital statistics, and the num-ber of deaths was 7,348.

In 1962 only 5,996 malaria patients wereregistered, and there were no deaths frommalaria.

A sum of 8.5 million quetzales was in-vested in this program, including this year'sbudget, and in addition to Guatemala, theGovernment of the United States of Amer-ica, the Pan American Sanitary Bureau,and UNICEF cooperated in financing theprogram.

This has been the cost of reducing ma-laria morbidity and mortality, but it has

also led to an increase in the populationand to a rise in agricultural production inpreviously endemic areas to more than$8,000,000 in an area measuring 80,350 km2,during the period 1960-1962. If the cam-paign is not completed and malaria is noteradicated throughout the country, we shalllose not only this investment but also some$150,000,000 in the next 15 years, calculatedat the rate of a daily per-capita productionof 2.50 quetzales; in addition, the agricul-tural production in the endemic areas woulddecrease because of the lack of workers.To this, the costs of hospitalization wouldhave to be added.

Eradication will be completed by 1967,and an investment of $3,500,000 in the nextfour years will be essential. Plans have beencompleted for financing a long-term loan toavoid the disastrous results which an inter-ruption of the campaign would bring.

In malaria eradication it is of vital im-portance ta integrate efforts at the regionallevel, in order to prevent border reinfesta-tions from endangering the achievementsmade in local campaigns.

II. CONTROL OF GASTROINTESTINAL DISEASES

In 1960 infectious and parasitic diseasesof the digestive tract caused 20.1 per centof all deaths, and the age group most af-fected was children under five years of age,accounting for 65 per cent of the total.

The close link between environmentalconditions and the prevalence of these dis-eases make it essential to attempt to solvethe problems of the lack of potable waterservice, of sewage and waste disposal serv-ice, and of poor housing. According to therecommendation of the Charter of Puntadel Este that these services should be fur-nished to at least 70 per cent of the urbanand 50 per cent of the rural population ina period of 10 years, studies were made andplans drawn up to expedite this task. InGuatemala 25 per cent of the population

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live in urban areas and only 42 per centhave water service in the home; 600,000persons in urban areas have no drinkingwater service. The most recent latrine pro-gram covered 44 per cent of the urbanpopulation.

In rural areas, which have a population of3,010,513, only 12 per cent have this kindof public service. During the fiscal years1960-1961 and 1961-1962 Guatemala in-vested a total of 2,352,500 quetzales, andfor the fiscal year 1963-1964 a sum of3,544,500 quetzales from the nation's regu-lar resources.

These figures show the Government's con-cern for solving the problem of diseasesarising from the environment, but it is inno way possible to attain the goals pro-posed at Punta del Este with these re-sources.

With the aid of a loan from the Inter-American Development Bank, Guatemalahas initiated a program to provide waterservices in 41 villages, and sewerage will beprovided to 15 others. The cost of thisprogram is $5,000,000. Other projects areunder way, but with the present resources,even if the programs are completed, theywill barely keep pace with the naturalgrowth of the population.

Studies have shown that when severalagencies engage in constructing such serv-ices separately, there is useless expense andmore general plans are frequently ham-pered. The creation of a semiautonomousagency is therefore necessary, not only toplan, but to build and supervise the admin-istration of these services.

The provision of drinking water to therural population is even more difficult and,in order to cover 50 per cent, as recom-mended at Punta del Este, Guatemala willhave to invest 25 million quetzales.

According to a study made by the PanAmerican Sanitary Bureau, the provisionof drinking water to 70 per cent of theurban and 50 per cent of the rural popu-

lation in Guatemala will require an invest-ment of 58.6 million quetzales in 10 years.

Some private and official bodies are atpresent attempting to cope with the housingproblem. The Government has created theInstitute of Insured Mortgage Promotion,which it is hoped will encourage private in-vestments for housing construction. Changesmade in the Savings and Loan Bank Lawwill make it easier for private persons toobtain funds for building purposes. TheRental Law controls rents in favor of low-income families.

The National Housing Institute wascreated to plan and execute housing pro-grams for the needy. Finally, the Inter-American Cooperative Housing Service,through a system of mutual aid and self-help, has undertaken to build 2,568 housesat a cost of 6.1 million quetzales; 57.1 percent of the capital for this program comesfrom foreign aid.

III. NUTRITION

It is difficult to determine from a study ofthe deaths what influence malnutrition hason the mortality rates in a country whereonly 13 per cent of the deaths are certifiedby competent personnel, but it can be cal-culated according to international stand-ards. The figures are alarming. Guatemalahas the highest mortality rate in the Con-tinent for the under-five age group. Theunfavorable influence of malnutrition onmorbidity and mortality caused by infec-tious diseases gives the malnutrition prob-lem indisputed priority.

In 1958 Guatemala issued a decree mak-ing salt iodization compulsory. A surveyamong 20,000 children made in 1951 showedthat 32 per cent were suffering from en-demic goiter; after only two years of opera-tion of the iodization law the frequencywent down to 16 per cent.


Protein deficiency is perhaps the severestform of malnutrition in Central America.INCAP has developed the vegetable mix-ture called INCAPARINA, which has proveneffective in the laboratory and in practice,and is helping to overcome the problem ofprotein deficiency.

The Governments have not made enoughefforts to bring INCAPARINA into general use,yet its production, which is in the hands ofprivate manufacturers, does not meet theneeds of the market.

IV. PLANNING OF HEALTH

SERVICES

Guatemala's first National Plan of Eco-nomic Development, for the five-year pe-riod 1955-1960, included health programs asan important step in the implementation ofthat plan; they were to cost 250,000,000quetzales.

When the Plan was revised, according toprogramming techniques, Guatemala allo-cated 13,355,000 quetzales in the presentfiscal year solely to health programs.

Health planning activities were institutedafter an investigation had shown that thebasic requisites for initiating planningexisted. A program of work consisting of thefollowing points was established:

a. Preparation of a basic document for

the creation of a Planning Unit at theministerial level.

b. Production and utilization of statistical

data in general, and of public health datain particular.

c. Organization of the services, and thechanges necessary for planning.

As part of the health planning process,the Ministry of Public Health and SocialWelfare will be completely reorganized, insuch a way as to allow health services to beintegrated and thus to obtain a higher yieldfrom the present resources.

Another of our problems is the markedshortage of both professional and auxiliarypersonnel. On the basis of the physician/population ratio in other countries, Guate-mala needs 3,000 more professional person-nel. At present our School of Medicine isgraduating 83 less physicians each yearthan are needed to keep pace with the nat-ural growth of the population, so that theproblem becomes aggravated with eachpassing year. The same holds true forauxiliary personnel. One of the more im-portant aspects in reorganizing the nationalhealth services will be to increase the ca-pacity of the School of Medicine and tocreate additional schools, or both. The sameapplies to training centers for other per-sonnel.

To cover its planning needs, especiallypersonnel training, Guatemala requires anincrease in the technical and economic as-sistance it has been receiving from the in-ternational institutions and agencies.

In sum, it will not be possible to solve thehealth problems without the disinterestedcooperation of all the countries of theAmericas.

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ADDRESS BY THE SECRETARY OF HEALTHAND WELFARE OF MEXICO

DR. JOSE ALVAREZ AMEZQUITA


As already stated by the Director of thePan American Sanitary Bureau, Dr. Abra-ham Horwitz, this is an historic Meeting,comparable to the one held in 1902 whenthe Bureau was established.

We are to join efforts here to solve thecommon problems of Latin America in thematter of health as it relates to the economyand in accordance with each country'scharacteristics.

Insanitary conditions, ignorance, andpoverty are the common problems in LatinAmerica and constitute perhaps its commondenominator. Vigorous economic develop-ment cannot be thought of unless theAmerican man is invigorated also, for he isnot only the producer of consumer goods butalso the basic instrument for attaining abetter level of living and a higher degree ofdignity as is befitting the people of America.

It can be said that any amount spent onpublic health is not an expenditure but aninvestment, from two points of view: an in-vestment in man's happiness and an invest-ment in his productivity. This is bestexemplified by our malaria eradication pro-grams.

Mexico used to lose 600 million pesos peryear as the result of absenteeism and diffi-cult working conditions in the malariousareas. And our country had many areaswhere man could not live, precisely becauseof malaria. In the seven years of planningand conducting our malaria campaign wehave spent only 580 million pesos, 80 percent of which was contributed by the Gov-

ernment of Mexico and the remainder byinternational agencies. In other words, byinvesting 580 million pesos in health andeconomic development we have spent lessthan we used to lose in a single year. Thisis perhaps the best demonstration of thefact that any money devoted to publichealth is an excellent investment.

Moreover, this action has opened up vastareas for agricultural development and forthe establishment of industries as well. Aplace like Pemex City in Tabasco, Mexico,could never have existed, despite technicaladvances, without the malaria campaignwhich made it possible to exploit the under-ground oil and establish an oil-chemicalcomplex.

Another important point is that ourmorbidity and mortality rates are decreas-ing, but we can almost categorically statethat this is due not to the development ofthe country, but rather to the investmentswe made in public health. That is to say, thereduction of our morbidity and mortalityrates is not the consequence of the country'splan for general development, but ratherthe consequence of the basic health careservices we provided. I believe that thisholds true for the other Latin Americancountries as well.

From the financial point of view there arethree classes in our countries: the finan-cially strong, who are able to satisfy theirhealth needs and frequently go to othercountries to seek a cure for their disease;those who are insured through systems

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established by our Governments such associal security, which protects a specialsector of the population; and finally, thefinancially weak, who are, so to speak, theconcern of the Ministry of Health and Wel-fare and of our Public Health Service. Ofthe total population of approximately38,000,000, at léast 20,000,000 are the con-cern and responsibility of the Ministry be-cause they are financially weak. We mustpay greater attention to them because theirurgent needs call for urgent care.

Where are the financially weak found?For the most part they live in the ruralareas of Mexico, and in the rural areas ofall America. In the belts of poverty thatsurround our cities live another set ofpeople who also need our aid. But if weexamine the relative needs of the man liv-ing in the country and the man living in thecity slums, it is clear that the rural dwell-er's problem is the more urgent.

Nor should we forget that the campesinois the heart and soul of our America andthat we owe him a great debt because, inspite of living under the most adverse condi-tions, he still takes care of our agriculturalproduction. We have not yet gone beyondthe agricultural stage in our countries, andour farmer-the campesino of all theAmericas-continues to labor in an un-healthful environment, in extreme povertyand ignorance; and his ignorance is not onlyof public health, but of everything, evenagriculture. That is the reason why in ourcountries agriculture is not advancing asrapidly as we would wish.

Moreover, it is not possible to conceiveof programs which are not directly aimed atthe well-being of man. By improving thehuman condition, therefore, the very eco-nomic development we are planning willcome about, for man is its basic element.Another thought to be borne in mind is thatwe must strengthen the inhabitant ofAmerica, especially the farmer. The reasonfor this is obvious: our American campesino

usually has a red-blood-cell count of lessthan three million, and a high percentage ofhis children suffer from proliproteinemicedema, resulting from deficient nutrition.

How can we expect the farmer of Americato work efficiently with a red-blood-cellcount of only two and a half million andwith far less than 12 grams of hemoglobin?Obviously, he has neither the strength northe capacity to work. Yet in spite of this hecooperates. How can we expect our race tobecome increasingly productive whenundernutrition starts at the mother's breastand results in the retarded mental develop-ment of the infant, who later, even thoughhe may receive food, can no longer recover?How can we expect our farmer to think andbe active when, in addition to his inade-quate food intake, he has no water?

I am convinced, and the other Ministershave already so stated, that each of ourcountries has its own program of develop-ment. The Alliance for Progress is not apaternalistic enterprise, and we must notexpect everything to come from it. We mustcontinue to promote our own programs andhave recourse to the cooperation offered bythe Alliance to accelerate the attainment ofbetter levels of living for our farmers.

On the other hand, our America is grow-ing at a truly extraordinary rate. The popu-lation growth is very high and is rising ata far faster pace than the rate of economicadvance. Mexico's population growth rate,as stated in numerous publications and asreported also by many of the Public HealthMinisters, is notable. This rate-about 3 percent-means an additional 1.3 millionMexicans each year who have to be fed,clothed, housed, and educated. Unless thisnew population becomes a productive forcefor Mexico, or for any other Latin Americancountry, making it possible to expand andincrease economic development, it will be-come a problem. For this reason, manyfactors must be borne in mind, and the fact

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that man is the basis of all activity mustnot be lost sight of.

We cannot conceive of the economist whoplaces man at the end of a series of proc-esses to attain the benefit; we see man asthe basis of action from the very start of thedevelopment programs. To our mind, manshould be happy and have his basic needsfulfilled, whether he is building a road, pro-ducing in a factory, or wherever he is work-ing. In the final analysis it will not be hissocial position which will allow him to behappy. What needs to be thought of rightnow is how to solve the problem of hisneeds, the essential component for him toattain his dignity. To this end, we must at-tempt to satisfy his basic demands, andprograms must therefore be begun withouttoo much prior planning, for it may happenthat, although a program may be admira-ble, it may yet be sterile. The basic con-cerns to be taken care of through programsrevolve around water supply, food, housing,clothing, and education.

Water is essential to the farmer. We haveheard that 90, 95, or 100 per cent of therural population lacks water-and yet ourbody is made up of water, 80 per cent of it.And I am going to say something that mayperhaps be revolutionary: Let us give themwater, even if it is not potable; we shall findthe means to make it potable later, becausethe man who is thirsty is the man who can-not live. A community which has water is acommunity capable of change, and it canacquire much happiness. Naturally, wateris very important in large cities too, but itis even more important in rural areas. Theoccasion comes to mind when one of ourcollaborators was visiting a rural areawhere there was a little rural school with apuddle of water next to it; the visitor seri-ously recriminated the teacher and askedhim to take steps to remove the puddle, asit was a health hazard. The teacher replied:If that puddle were dry, what would Idrink? This may give you an idea of the

drama, the extent of the thirst for waterthat is felt in the Americas.

Therefore, we should like to state thatthe provision of water-and basically,water for rural areas-demands a firstpriority in all our health and welfare pro-grams.

Next, man has to eat. And here, too, I amgoing to state another revolutionary idea:For the moment, let us not seek a diet per-fectly balanced in proteins, carbohydrates,fats, vitamins, and minerals, especially forour rural inhabitants. The important thingis to feed the people; so let us provide themwith more beans and corn, or more corn andbeans, for our people, at least in Mexico,are a corn-eating people. Once their basicneed to eat has been satisfied, then all thespecial proteins of animal origin you wishcan be added; and the suitable amounts ofvitamin can then be added to make themstrong.

Housing, too, is basic. Without decenthousing, it is equally impossible to conceiveof the dignity of man. Programs to improveexisting houses and build new ones areabsolutely essential, and should be allottedthe third priority.

Clothing is also a basic need, for man hasto cover his body. One of my country'sachievements I want to tell you about isthe program to furnish ready-cut clothingto the campesino, at cost price. With 15.50pesos, a countrywoman can have a dress,which she can sew up under the auspices ofa mother's club at the health center, wheresewing machines are provided. In our ruralareas the community is basically motivatedby the women. When the woman has sewnthe dress, she can either wear it herself orsell it. The market price of such a dress is80 pesos. If she sells the dress she herself hassewn, she can earn from 10 to 15 pesos,which gives her that much more to buy foodwith and therefore to eat, or to otherwisehelp out with family finances.

We have sought the most economical


means with which to build houses wherepeople can live in dignity, and we havefound that such construction can be done,including windows, screening, and suitableroofs, for 8,600 pesos, or about US$700.

We also try to improve the activities ofour people through our programs of educa-tion, which are included in the Govern-ment's general program for literacy and foreducating the child; and through schooltextbooks prepared by the Government,which contain chapters on public health,so that children may begin to understandwhat it consists of and form a clear conceptof it.

We must strengthen man, especially theman in the field who has hypoproteinemia,the man who is full of parasites. We cantruly say that the miserable taenia is ca-pable of stupefying an entire people, sincethe parasitic rate among our rural popula-tion is extremely high.

To carry out the programs in rural areas,along with the others and within the frame-work of a new public health concept, weneed the cooperation of the people. That isbasic. We must not give them a paternal-istic gift. They must participate activelyand assume the responsibility for establish-ing health care activities. I am so firmlyconvinced of this, because the poor farmersof Mexico contributed 3.5 million pesos lastyear; and they are now contributing 5,000pesos to the establishment of a new, perma-nent health center which, with equipment,will cost no more than 65,000 pesos. In ad-dition to money, the people also furnishedpart of the labor and have in that waycome to feel that the center is theirs, andnot charity or a gift from the Government;it is thus an active force in which they tookpart and from which the entire communitycan benefit. And this is important, becausethe sense of ownership and of giving service-even if small because it is rural-is re-placing the health team that used to passthrough the village every 6, 12, or 18

months, and has instead given the village apermanent health center, one in which theythemselves cooperated actively to improvetheir situation. In this way, health centershave come to many places before roadsand electricity, since it is the center thatpromotes the desire for community im-provement. And the next step is to bring themiracle of water. All that is needed is a littleprodding and guidance, and the communitywill improve its living standard. This iswhat we have achieved through the healthcenter. This is why we have a sanitationand rural community organization service,since a rural health center in itself wouldnot suffice to improve the community. Thecommunity needs to learn to meet its ownbasic needs, to take better advantage ofavailable food resources, and to establishsmall industries so as to improve itseconomy.

Therefore, at each rural health center, inaddition to the mothers' club, there is a millwhere women can grind corn into nixtamal.On one of my tours I was surprised to findthat one woman had walked four kilometersto the mill, where she paid 10 centavos fora kilo of ground nixtamal.

By organizing a consumer cooperative,with one mill for nixtamal at each healthcenter, we have succeeded in dignifying thewoman, who no longer needs to grind cornon her knees but can now do so standing up,because we have furnished a table on whichshe can place her metate. By providing thissimple mechanical element with which togrind corn for the masa that is their dailybread, we have liberated women from kneel-ing at the metate for two to three hours eachday, and have made it possible for them touse that time in other constructive pursuits.

Man's basic needs, therefore, are in thefirst place, water; then food, housing,clothing, and education. In the rural areasthis will be the basis for a program whichI should like to submit to your considera-tion. It is a program of basically rural

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activities within a section of the Alliancefor Progress, and is intended to meet thesebasic needs, in addition to our health pro-grams, and to expand these activities untila level compatible with human dignity isreached.

In the second place I shall refer-not tohospitals, which are certainly important butrequire a great deal of money, nor to ourneed for many specialized technicians,which we do have, good or bad; I shall in-stead refer to the more urgent need for pre-ventive programs, which will keep our hos-pitals from being filled up. Fortunately,hospital planning is based on the new con-cept of public health which combines pre-ventive with curative medicine. Formerlythere was the absurd situation in that nopublic health physician was permitted tocure and no general practitioner was per-mitted to practice preventive medicine. Nowwe have achieved the integration of the pub-lic health concept, and we have all becomehealth soldiers. The general practitionergrows in stature by practicing preventivemedicine, and the public health physiciangrows in stature when he practices medicalcare. It is absolutely essential for these twoconcepts, prevention and cure, to become asingle unit, and this is already happeningin Mexico. We have health centers and theenormous advantage of them is that pre-ventive and curative medicine are housedin the same premises, and that the labora-tory and X-ray equipment are shared byboth specialities. You can verify this in yourown countries: X-ray equipment which atthe health center takes only some 50 X-raysper month at a very great cost, can be usedto maximum advantage if it is utilized byboth preventive and curative medicine inthe same place and at the same time, withthe sole aim of leaving hospital beds freeand keeping them from becoming occupied.From the theoretical point of view thiswould be almost perfect, if it were to bedone in the way I have described.

It is obvious that we need good productsto conduct a preventive campaign. But ifour biological products are poor in quality,we lose all the investment we have made inhealth administration. It costs exactly thesame to apply a poor product as to apply agood one; the only difference is that thegood product will bring favorable results,while the poor product will be useless, aswill be the money invested in health admin-istration. This means then that we needgood and inexpensive biologicals, for costbecomes important when application tolarge numbers of people is intended. I there-fore take.the liberty of making the follow-ing proposal on behalf of Mexico: I shouldlike to suggest the advisability of creatinga Latin American common market for bio-logical products. I do this on the basis of anexperience we had: in order to speed upthe poliomyelitis campaign in Mexico, wehad to send one of our experts, Dr. ManuelRamos Alvarez, for a three-year trainingcourse in methods of preparing the vaccineused by Dr. Sabin. Dr. Ramos Alvarez is aworld authority in virology, and on com-pletion of his training we installed thelaboratory in which trivalent Sabin vaccinewas to be prepared. It represented an in-vestment of some 3.5 million pesos. Sincethat time the laboratory has produced 22million doses of the vaccine, which at thecommercial price of 10 pesos per dosis,totals 220 million pesos. This is an expendi-ture the Government could not have madewithout great difficulty. Moreover, it hasenabled us to send this vaccine to othercountries in the Americas as a token ofMexico's solidarity with its sister republics.It was then that I developed the idea of aLatin American common market for bio-logicals which, under the Alliance for Prog-ress, would enable us to solve our own prob-lems by bringing down the cost of theseproducts.

The planning could be as follows: to drawup a list or catalog of our needs and to make


an inventory of existing facilities, sincesome countries are already manufacturingbiologicals. In other words, to make a list ofwhat at present is being produced at thegovernment-not the commercial-level, inorder to keep prices low and to exchangethese products among the countries of theRegion. Also of importance would be totrain the necessary personnel and to planthe industry on a regional basis, so as todetermine where new laboratories need tobe set up; in this way Latin America wouldbe supplied by its own production, withgood quality products at prices withoutcompetition, and in amounts sufficient tomeet the needs of an ever-increasing popu-lation. The products would be guaranteedby the Pan American Sanitary Bureau,through quality control by the National In-stitutes of Health.

The polio vaccine manufactured inMexico is very good and inexpensive, and isbeing used to immunize the greater part ofthe financially weak population. But I amnot referring only to Mexico's polio vaccine;there is also the yellow fever vaccine pro-duced in Colombia, the vaccines produced inChile, and the biological products of Brazil.I should like to point out the possibilitiesfor personnel training in our countries,which could make us self-sufficient in themanufacture of biologicals, and therebysatisfy the need for strengthening the greatmasses of Latin American population whichare financially weak.

I sincerely believe that the initiativewhich I am submitting to your considera-tion should be carefully examined by all,with a sense of solidarity, so as to plan theestablishment, on the basis of our own re-sources, of a common Latin Americanmarket for biological products, to supplythe rural population of Latin America withwhat they need to rid them of disease.

Personnel training is another concern ex-pressed here by the Health Ministers. Butpersonnel must be trained at all levels, not

only at the Johns Hopkins University level.What we need are true health promoters inthe rural communities, so we must urgentlytrain rural nurses. In this regard, our ex-perience has been as follows: a rural com-munity nurse with 9 to 10 months' trainingis placed in a small rural health center,located in the Indian area. This nurse is ayoung, bilingual girl who speaks both Span-ish and her native Indian language. She isthus in her own community and firmlysettled there; she is contributing to its eco-nomic and social development, and she isable to do so because she has the advantageof speaking its language and hence inspiringconfidence. By saying this I do not meanthat I am opposed to having a graduatenurse in such a community, but we shouldutilize also any human resources we haveamong the population; we should avail our-selves of those people who can be interestedin health problems, and with them form thebasic elements which will promote in ourcommunities an awareness of health and oforganization.

Obviously, planning must be both re-gional and local, as our colleague fromGuatemala has stated. We do not want amalaria mosquito from Mexico to go intoGuatemala, but neither do we want aGuatemalan mosquito to come to Mexico.There is no way to put up a large net at theborder with a sign reading: "Mexican orGuatemalan mosquitoes are not permittedto cross." That is precisely why regionalprograms should have a common ideal. Inthis regard, I should like to report thatMexico and Guatemala have exchanged thenecessary information, and that malariasquads from Guatemala have crossed intoMexican territory, in order to re-enterGuatemalan territory at some other pointin their campaign against malaria. It isabsolutely essential that we regionalize ourplans, for our needs are no longer simplygeographic or political; our program is com-mon to all Latin America.

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The improvement which the Region ex-pects from the Alliance for Progress shouldbe closely linked with the establishment ofsources of production. It is not a question ofbeing given money, which will only partlysolve our problems; it is a matter of ourusing our imagination to promote generaleconomic development, which is not in ourhands. For the moment, we can promote theimprovement of our sources of production ofbiologicals, as I have just stated, and thismay prove to be a basic measure.

Mention was made of death certificates.It is true that our statistics are often faulty.In Mexico one half of the death certificatesare signed by physicians and the other halfby Civil Registry officers who know nothingabout medicine. Among the causes of deathappearing on the certificates, therefore, attimes a poor hysterical person is indicatedas having died from yellow fever, simplybecause he looked yellow to the Civil Reg-istry officer, and this in a place located at analtitude of 2,000 meters, where there is noAedes aegypti and where no person couldever die of yellow fever. It is not that I amagainst statistics, but what we are inter-ested in is knowing in general terms thesituation under discussion without havingto invest enormous amounts of money toobtain overly precise data which, by theirvery precision, might prove imprecise orincapable of guiding us in planning our ac-tion; and without a detailed investigationon morbidity such data will not be definitiveand will therefore be wasted. It would bebetter to use that money on a more socialand more effective program.

In conclusion, and to sum up what I havesaid, I should like to formulate two pro-posals for you to discuss.

The first is the creation of an agency tostudy the health problems in the rural

areas of Latin America from a regionalviewpoint. Thus, first of all, rural areas;and as for the agency, it might perhaps beclosely linked to the Pan American SanitaryBureau and reflect the wishes of each of ourGovernments in the matter of satisfying thebasic needs compatible with human dignity.I would propose that the first program bewater and nutrition, since they are of basicimportance; and then housing, clothing, andeducation. But the basic one is water. Wecould then plan, with a special fund perhapsfrom the Inter-American DevelopmentBank, a definite program aimed at meetingthis basic need for strengthening theAmerican population. First, water in ruralareas; then, food in rural areas, which isequally important; and then housing, cloth-ing, and education.

My second proposal concerns the need toplan, as soon as possible, a Latin Americancommon market for good quality, inexpen-sive biological products. This should be atthe government level, so as to cover most ofthe needs of preventive programs in theAmericas, and the Continent should bedivided into zones so as to obtain a logicaland suitable exchange of these products. Itwould save us a lot of money, which couldbe used to better advantage for the benefitof the large masses of population.

Finally, I should like to state that I havefaith in the destiny of America and in theman of Latin America; our farmer onlyneeds us to give him a hand in order todevelop. I have equal faith in the Alliancefor Progress, not as an ideal panacea tocure all our ills or satisfy all our needs, butas additional aid in the efforts we all mustmake in order to develop our health plansand achieve economic progress, essentiallyfor the benefit of the financially weak ofLatin America.

ADDRESS BY THE SECRETARY OF STATE FOR HEALTH AND SOCIALWELFARE OF THE DOMINICAN REPUBLIC

DR. SAMUEL MENDOZA MOYA

Presented at the Fourth Plenary Session16 April 1963

We have assuredly assembled here forthe purpose of continuing to give practicaldirection to the revolutionary calling of theAmerican peoples. Never before have thesepeoples had ahead of them so magnificent aroad as the one laid out by the idealists ofPunta del Este, when the latter declaredtheir decision "to unite in a common effortto 'bring our people accelerated economicprogress and broader social justice withinthe framework of personal dignity andpolitical liberty," as expressed in the Pre-amble to the Charter of Punta del Este.

We may say that the dreams of theAmerican liberators are now fulfilled bythis far-reaching document. It epitomizesthe eagerness of the present democraticleaders of this Hemisphere, who are con-tinually making greater efforts to givespiritual and material support to the peo-ples of the Americas.

In consonance with this historical man-date and its foreseeable accomplishments,the Dominican Republic has drawn up itsNational Public Health Plan, which en-compasses the years 1963-1972, inclusive.

I am happy to lay this Public HealthPlan before my American colleagues, in thebelief that it can not only serve as a sourceof information but will also lead to en-couragement and suggestions for countrieslike ours.

The bitter facts highlighted in our Ten-Year Plan serve both to reveal the situa-tion in our country and to establish priori-ties for corrective action. They are aninhuman and cruel reflection of a political

system which, thanks to God and to theefforts of good Dominicans, we left behindand to which we shall never return despiteefforts to induce us to do so.

Obviously, during this sequence of politi-cal and social circumstances, it was difficultto make an exhaustive study of the mostimportant aspects and of national needs.But during the few weeks which havepassed since our Government took office, theNational Health Plan has not been rele-gated to a secondary place. In this connec-tion, I am happy to declare in the name ofmy Government, and in my own, as Secre-tary of State, that the sole aim of ourhealth policy is to continue to put the Ten-Year Plan into effect.

Imbued with a truly American spirit, Iam reporting, through this Plan, our effortsto solve each of the health problems whichhold back economic and social progress inmy country.

Today, unhappily aware of the lack ofpure drinking water among two thirds ofour people, I have recourse to a symbolicaltoast with a glass of water, asking my col-leagues and men of good will of the differentinternational organizations to pray thatsoon, thanks to the common effort, the menof America, both the country and the citydwellers, their wives and their children,may drink water as pure as that we aredrinking in the capital of the United Statesof America.

Among the recommendations of'the meet-ing of the Inter-American EconbOmic andSocial Council at the Ministerial Level, of

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the Alliance for Progress, is that of supply-ing water and sewerage services to not lessthan 70 per cent of the urban and 50 percent of the rural population in the nextdecade. Another major concern is to pro-tect, among other groups, one of the mostvulnerable segments of the population,namely, children under five years of age.But the subject we have chosen for ourstatement here is the water problem inLatin America.

It is no exaggeration to say that thesanitary engineering situation in LatinAmerica is critical. We must make boththe Governments and the peoples realizethat, in order to advance in the field ofhealth, we must face this problem, chan-neling all our national resources towardbettering the conditions prevailing in watersupply and sewage disposal services.

In Latin America there are now 22.7million inhabitants in urban areas and 86million in rural areas without water supply.

Assuming a population increase of 2.5per cent per year for the next 10 years inurban and rural areas, we find that theexpenditures necessary to achieve the ob-jective of water supply for 70 per cent ofthe urban and 50 per cent of the ruralpopulation within this period amount to 40million dollars per year in urban areas and51.6 million per year in rural areas. Thisamount is clearly beyond the economic ca-pacity of the majority of the Latin Ameri-can countries.

Consequently, we must adopt measuresby which we can obtain the active partici-pation of the communities. We must edu-cate the masses so that, on accepting theobligation to contribute to the solution ofthe problem, they share jointly with theGovernments in amortizing the investment.

With these achievements as the goal, wemust encourage the creation of organiza-tions- which, at the national level, willpolarize the government services and thepeople in facing this serious problem.

With respect to the water problem in theDominican Republic, I shall describe thesituation from the technical, economic, andhealth points of view.

According to statistics, 20 of the 95 urbancommunities of the country lack watersupply systems. As for the rural areas, onthe basis of scanty and inexact data, wemay conclude that about 8 per cent of theinhabitants have water supply facilities, themajority being indirect supplies by wind-mill. The data on water service in urbancommunities indicate that about 40 per centof this population has a direct supplythrough house connections, and that 60 percent lack water service.

The initiation of a national program toincrease the proportions of the populationserved to the minimum levels of 70 per centin urban and 50 per cent in rural areas, bymeans of a ten-year plan, is under discus-sion. The problem is not the simple one ofsupplying a fixed number of inhabitants.Through progressive expenditure on sanita-tion works, we must extend these servicesin proportion to the rate of populationincrease, which varies, on an average, be-tween 2.5 and 4 per cent per year.

With respect to sewerage systems, aneffort is being made, within this total pro-gram, to furnish this service to cities withmore than 10,000 inhabitants.

As for the economic problem, we shallbegin by estimating the annual investmentnecessary to finance the program. Unitcosts, on the basis of which the approximateamount of the investment is calculated, aredrawn from projects recently completed inthe Dominican Republic. We can take it,then, that these figures are representativeof the cost of this type of work in ourcountry. The additional population to besupplied by 1973 will amount to about1,100,000 inhabitants; of these, 120,000 arein communities without this service. It isestimated that the number of inhabitants


in the rural areas to be supplied will be3,000,000.

Taking into account these data and thepredetermined goals as to the populationto be supplied, the situation is as follows:population to be supplied, 4,100,000 inhabi-tants; total expenditure, $47,300,000; an-nual investment, $4,730,000.

As to sewerage service, the program willbe limited to furnishing this service tocities whose present population is in excessof 10,000 inhabitants.

To sum up, these figures indicate thatthe annual investment for the program willamount to 6.55 million dollars, plus interest.Assuming that 80 per cent of the annualexpenditure is to be borne by the urbanpopulation, the execution of the programimplies an annual per-capita contributionof $5.70 for residents of urban areas and of$0.62 for inhabitants of rural areas.

However, this economic approach to theproblem requires the establishment of insti-tutions technically and financially equippedto solve the problem in a national plan,with the aid of the Governments and inter-national credit institutions created for thepurpose.

This fact led to the creation of the Na-tional Water Supply and Sewerage Institutein the Dominican Republic.

The sanitation measures that are mosteffective in helping to reduce mortality

rates are those taken to increase watersupply and sewage disposal services.

Among these measures the outstandingones are those providing for technical con-trol and regulation of methods used in thepurification of water for human consump-tion and in the treatment of sewage.

In statistics for children under five yearsof age, the enteric diseases appear as theprevailing cause of mortality.

From all this, it is evident that changesin the methods used for control of thequality of water for the consumer must notbe put off.

From what I have said, the followingconclusions emerge:

1. That national programs to extend po-table water supply and sewage disposalservices to those parts of the populationwhich lack them must be initiated.

2. That, because of the considerable costinvolved, the people and the Governmentmust share in financing these programs.

3. That in order to coordinate this workit is desirable to encourage the creation oftechnical organizations at a national levelto plan, operate, and administer publicwater supply and sewage disposal services.

Before closing, I want to express the hopethat the general considerations I have out-lined will be a challenge to the collectiveeffort to solve these very serious problemswhich give us concern.

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ADDRESS BY THE MINISTER OF PUBLIC HEALTH ANDSOCIAL WELFARE OF EL SALVADOR

DR. ERNESTO R. LIMA


I should like first of all, on behalf of theGovernment of El Salvador, to commendthe Organization of American States andthe Pan American Sanitary Bureau in thepersons of Dr. José A. Mora, SecretaryGeneral, and Dr. Abraham Horwitz, Direc-tor, respectively, as well as their colleagues.Pursuant to Resolution A.4 of the Charterof Punta del Este, this conference of healthworkers at the highest level has been organ-ized to assess existing problems and suggestgeneral lines of action of immediate effect,designed to achieve the following objec-tives: control or eradication of communica-ble diseases; environmental sanitation, pri-marily through provision of water supplyand sewage disposal services; reduction ofinfantile mortality, especially of the new-born; and improvement in nutrition. Weshould also like to recommend health edu-cation, personnel training, and improve-ment of services.

I also want to thank the Government ofour host country, represented by Dr. LutherL. Terry, Surgeon General of the UnitedStates of America, for the efforts it hasmade and the facilities it has provided forthis important conference. I would askDr. Terry to convey to the President of thecountry, John F. Kennedy, our gratitudefor the cordial and friendly words of hismessage of welcome.

El Salvador has such special characteris-tics that I want to mention them briefly, sothat those participating in the Meeting willhave a better understanding of our healthproblems.

Our country is situated in the center ofMiddle America; in surface area, it is thesmallest country of our Hemisphere. Itsgeographic location puts it at the normalcrossroads of migrations of the CentralAmerican people and the people of Northand South America. It is bounded on thenorth and east by the Republic of Hon-duras, on the south by the Pacific Ocean,on the west by Guatemala, and on thesoutheast by the Gulf of Fonseca, whichseparates it from its sister Republic ofNicaragua. Its location and its tropicalclimate are factors of great importance withrespect to the incidence of communicablediseases. Its territorial extent is about20,000 square kilometers, and its populationnumbers 2,511,000, making it the third mostdensely populated country in America, with125 inhabitants per square kilometer. Thispopulation situation is intensified everyyear by a 3-per-cent increase, which inround numbers means 70,000 more inhabi-tants every year. So we may predict thatin 1970 El Salvador will have 3,345,000 in-habitants, with a population density of 167per square kilometer.

The population of El Salvador is young;33 per cent are under 20 years of age, whileonly 3.4 per cent are over 60. Forty-eightper cent of the population over 10 years ofage may be considered illiterate, and 47.6per cent, or about 806,590 inhabitants, areeconomically active. Sixty per cent of thiseconomically active population is employedin agriculture, the basic activity in ourcountry. While it is certain that the figures

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for both general and child mortality havedecreased in recent years, it should bepointed out that the greater proportion(54 per cent of the total) are accounted forby children under four years of age, andthat these are conservative estimates, whichwould perhaps be higher if the statisticswere complete. I should point out that only22 per cent of the deaths are certified byphysicians.

In order of decreasing importance, theprincipal causes of death are: gastroenteri-tis, infections of the newborn, acute respira-tory infections, homicides, measles, tetanus,whooping cough, vitamin deficiency andother deficiency conditions, tuberculosis,and malaria.

We are glad to note that malaria, whichwas the first cause of death about 15 yearsago, has dropped to a very low place on thislist.

The Ministry of Public Health of ElSalvador receives 11 per cent of the totalbudget of the nation to devote to healthprograms. In spite of the fact that this isthe highest appropriation received in thehistory of the Ministry, a bare 46 per centof the population in need of medical atten-tion can be cared for with this amount.Moreover, for the medical care of the popu-lation there are 520 physicians, a ratio ofone for every 5,000 inhabitants. The doctorslive, for the most part, in urban areas;consequently, it may be said that the ruralareas lack health care. There are also 160dentists, one for about every 15,000 inhabi-tants; 150 engineers, 566 nurses, 1,700auxiliaries, 128 sanitary inspectors, and afew ancillary personnel. There are two hos-pital beds for every 1,000 inhabitants; thebeds are distributed in nine hospitals, ninehealth centers, and 59 health units.

I should not withhold the fact that theSalvadorian Social Security Institute, es-tablished eight years ago, now takes care ofbarely 40,000 insured workers living inthree cities. The Institute has been con-

spicuous by its failure to develop and toreach new groups of the people, as well asto take care of the families of insured work-ers. So it is easy to see how scanty the aidof this institution is in solving our healthproblems. It was created for this purpose,but it has not achieved it.

The Ministry which I head is extremelyinterested in finding a solution to thisproblem, and believes that it is of primeimportance to organize and coordinate só-cial security services in such a way thatthey can discharge the functions withintheir competence throughout the nation,extending them to all the working popula-tion. So we are collaborating in the task oftransforming national medical care, whichtraditionally was considered a benefactoryservice in Latin America, into an organiza-tion to whose support the citizens will con-tribute in accord with their economic re-sources, since we believe that no countryin the world is capable of giving free medi-cal care to 85 per cent of the population.

We understand that the solution of theseproblems is an obligation of our Govern-ment within the framework of the Alliancefor Progress. I am happy to state that ElSalvador is effectively fulfilling the obliga-tions which it contracted when it signedthe first title of the Charter of Punta delEste, in which the objectives of the Allianceare outlined. The top directors of the pro-gram have acknowledged it. In fact, in thelast two years El Salvador has adopted thefollowing institutional reforms: the law onpaid Sunday rest for agricultural workers;protective regulations covering agriculturalworkers; the temporary law on food pay-ments for agriculture workers; law to pro-mote poultry raising; rural welfare law;drainage and irrigation law; law to promotethe livestock industry; temporary law fix-ing minimum salaries for commercial em-ployees; law on the promotion of industry;law reorganizing the central national bank;amendment to the law creating the Salva-

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dorian Coffee Company; amendments, sub-stitutions, and additions to the income taxlaw; creation of the Salvadorian Institutefor Promotion of Industry; organic law per-taining to the Central Reserve Bank; fiscallaw of El Salvador; civil service law; lawcreating the National Council of Planningand Economic Coordination.

In the health field, the Planning Unitwas created at the ministerial level. ThisUnit has already begun its work and nowkeeps in close touch with the planning unitsin the Ministries of Education, Agricultureand Livestock, Public Works, and the In-terior.

We are putting great effort into malariacontrol, since, as you know, this problem isof enormous importance to us. Because ofunforeseeable biological phenomena, wehave encountered great difficulties, to thepoint where we have had to attack the dis-ease in the most integrated fashion; weare pursuing our eradication program withgreater intensity than in the past and giv-ing it absolute priority. In spite of ourpresent economic situation, spraying opera-tions have been renewed, and we have goneon to apply supplementary measures, suchas the use of larvicides. On 15 April, Mon-day of this week, a program of supplyingdrugs to about 80,000 inhabitants was ini-tiated.

In the malaria eradication campaign,about 1,048 voluntary collaborators aretaking part; last year they sent us 127,293blood samples, of which 7.9 per cent werepositive. Three of the 14 departments ofthe country are already in the consolidationphase. We think that these data will be amatter of satisfaction to our Central Ameri-can neighbors.

Smallpox was eradicated in El Salvadormore than 30 years ago. However, this yeara vaccination program designed to protect80 per cent of the population within threeyears was initiated.

I want to take this opportunity to make

public our thanks to the Government ofMexico for its aid in providing us with200,000 doses of smallpox vaccine and30,000 doses of poliomyelitis vaccine; thelast-named was for the immunization ofchildren up to two years of age in urbanareas of the country.

Tetanus vaccination of pregnant womenin rural areas was also begun this year, asa supplementary measure for controllingtetanus neonatorum. Our goal is to im-munize 27,784 future mothers.

We have also established as an objectivefor this year the vaccination against diph-theria, whooping cough, and tetanus of70 per cent of the children under one yearof age in urban areas, and of 30 per cent ofthose of from one to four years.

As to leprosy, in April of this year thecontrol of 228 known cases and the system-atic investigation of their contacts wereinitiated with the help of the Pan AmericanSanitary Bureau. Soon a tripartite agree-ment between a private Salvadorian foun-dation, the Pan American Sanitary Bureau,and the Ministry of Public Health will besigned; it will greatly facilitate the eradi-cation of this disease.

The nutrition problem is rather seriousand complex, as is the case in our sistercountries. In fact, we do not think it willbe possible to solve it easily within a shortperiod of time. A cooperative program isunder development; it involves the Minis-tries of Agriculture and Livestock, Educa-tion, and Public Health, and the Food andAgriculture Organization, the United Na-tions Children's Fund, and the Pan Ameri-can Sanitary Bureau. By virtue of its vastexperience, the last-mentioned will help usto train personnel to extend the programthroughout the country.

As for tuberculosis, the work of vaccina-tion, research, and treatment continues. Apilot control program covering an area withalmost 200,000 inhabitants is under dis-cussion with the Pan American Sanitary


Bureau and the United Nations Children'sFund.

I deem it necessary to put into the recordthe thanks of the Government of El Salva-dor to the Pan American Sanitary Bureaufor the technical aid furnished through itsZone Office in Guatemala.

With regard to Resolution A.2 outliningthe Ten-Year Public Health Program of theAlliance for Progress-paragraph 2-b ofwhich refers to potable water supply andsewage disposal for at least 70 per cent ofthe urban population and 50 per cent of therural-El Salvador created ANDA (Na-tional Water Supply and Sewerage Admin-istration), an autonomous organizationwhich has assumed responsibility for carry-ing out this program.

As Dr. José A. Mora noted in his openingspeech, it can be stated that, up until now,greater priority has been given to waterand sewerage projects for urban communi-ties. The Ministry of Public Health of mycountry has observed this development withdeep concern. Our concern is especiallystrong for the reason that since the creationof the organization mentioned above-ANDA-the Ministry of Public Health hasceased to participate in this program; itpreviously directed it with satisfactoryresults.

We suggest that our sister countries whichfind themselves in a similar situation, be-cause of the structure of the water andsewerage organizations, promptly study thechanges necessary to allow the Ministriesof Health to assume once more the neces-sary executive functions, for no program ofrural sanitation can be carried out unlesswater is first supplied to the communities.This fact is so self-evident that we mayremind ourselves that, to fulfill the mini-mum requirements of the Ten-Year Pro-gram of the Alliance for Progress withrespect to water and sewerage, we have only100 months at our disposal, and that weneed to construct an average of 12 services

a month in order to provide potable waterto 50 per cent of the rural population ofEl Salvador. If we remember that our waterauthority has not begun any rural work ofthis character since it was founded, theproblem is seen to be urgent. We call thispoint to the special attention of the direc-tors of the Inter-American DevelopmentBank, who have evinced great interest inthe Ten-Year Public Health Program.

We are convinced that it is possible tosolve our complex problems, so long as wecan count on effective and practical inter-national aid. In view of this, our presentGovernment, headed by Col. Julio Adal-berto Rivera, has emphatically declared-the last time at the conference of Presidentsof Central America and the United Statesof America, held in San José, Costa Rica-that its principal concern was for the publichealth and education programs, since wecannot even think of economic developmentin our country if education and health con-ditions are bad.

Likewise, when we signed the Charter ofPunta del Este, we did it in the convictionand certainty that this Alliance is foundedon the principle that aspirations for work,housing, land, schooling, and health are,among other needs, best attained throughpreservation of liberty and the institutionsof representative democracy. For that rea-son we accept confidently and enthusiasti-cally the statement of the Group of Expertsof the Organization of American States onPlanning for Economic and Social Devel-opment to the effect that improvementsin health conditions are desirable in them-selves, that they are an essential prereq-uisite for economic growth, and that there-fore they must be an integral part in anymeaningful development program.

At this time I want to repeat, in the nameof the Government of El Salvador, that wedo not believe it possible for a people wholack health to achieve economic develop-ment. Also, I wish to express at this Meet-

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ing the surprise and dismay we experiencedon hearing certain statements by some highofficials of the Alliance for Progress, whoconsider programs of economic developmentmore important for our countries than pro-grams for the prevention, promotion, and

-1 restoration of health. These statements areepitomized in this sentence: "Industry pro-

duces hospitals, but hospitals do not produceindustry."

I hope that what is said at this Meetingwill convince the leaders of the Alliance forProgress of the great significance and eco-nomic value of human health in the eco-nomic and social development of the Ameri-can peoples.

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ADDRESS BY THE MINISTER OF PUBLIC HEALTH OFCOSTA RICA

DR. MAX TERAN VALLS


With my first words I wish to convey afriendly greeting from the Government ofCosta Rica to the Ministers of our sisterRepublics, and to express to the Pan Ameri-can Sanitary Bureau my Government'sthanks for the aid and counsel the Bureauhas been giving it.

I must take cognizance of our reason forbeing here: in my opinion we must manifestto the Organization of American States therecommendations agreed to in the Charterof Punta del Este through the Alliance forProgress.

We understand that the Alliance forProgress marks the beginning of a socialrevolution in our Hemisphere; an orderlydemocratic social revolution, of course. Itis indeed clear that, to achieve the objec-tives spelled out in the Charter, we mustagree on our contribution in the health field.It seems unnecessary in a Meeting of Minis-ters of Public Health to discuss what typeof problems should have priority, when itis a question of the development of LatinAmerica. However, it is certainly desirableto make clear to those who, as the Ministerof El Salvador has said, still battle to placethe economic and social factor first, thatwe must advance concurrently in all fieldsif we seek effective development of theregion. Many obvious examples could becited to prove that health is of prime im-portance in the process of our peoples' de-velopment. We must understand this ac-celerated, though orderly, social revolution;moreover, along with the objectives that we

have in common, we must understand andmake known the fact that each country hasits special features. The respective develop-ment programs must be studied by the gov-erning bodies of the Alliance for Progress.If the unceasing effort we are making is putto advantage, those objectives can be at-tained, taking into account the special con-ditions in each country.

I believe that our contribution to theAlliance for Progress is somewhat ideologi-cal, since, as free American men, we allresist any efforts to contaminate us withpolitical ideas and concepts incompatiblewith the liberty of the American peoples.We shall oppose such invasions. Moreover,our collaboration in this undertaking hasbeen made clear by the fact that all ourMinisters, in accord with recommendationspreviously agreed to, have set their Minis-tries-and Costa Rica's, too-to the taskof planning, and have gone on to an evalua-tion of our health problems which showsthat we have done as much as possible tosolve them and that, consequently, we de-serve effective assistance.

I do not want to go into detail, but I dowant to mention certain matters which havedemanded attention in the course of ourGovernment's work on health problems.

The principle, grounded in statistics, thathealth policy must be basically orientedtoward rural populations has already beenpointed out here. Our rural population,which makes up not less than 60 per cent ofthe Continent's population, needs immedi-

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ate help in the plans for development. Onemust not forget that this rural populationis the most impoverished and possesses theleast economic resources. Accordingly, if wewant to contribute to the speedy develop-ment of our respective countries, we mustprovide our workers and farmers with con-ditions that permit a greater productivity.Rich and well-fed peoples must understandthat the production of our population can-not equal theirs.

In the rural field two problems demandattention. In the first place, water supplyhas been mentioned as the prime problemin environmental sanitation. I agree withthis appraisal of the situation. While we areconcerned about maintaining and betteringwater supply services in urban areas, thereis no doubt that the problem in the ruralareas is a much larger one. But for the veryreason that the economic resources of ourrural peoples are much lower and also be-cause it is easier to obtain credits to solvethe problem of the lack of drinking water inurban areas-since the cost is recoverablein full-we must emphasize the fact thatthe greatest obligation is to establish suit-able water systems in the countryside, andthat it is the duty of the respective Statesto give their chief attention to this goal andincrease the public health budget in orderto be able to help these rural peopleseffectively.

I want to submit to the consideration ofthe Ministers an idea which has been stud-ied, so far as we are concerned, by theWater and Sewerage Institute of CostaRica. We think that rural water-rate sched-ules ought to be fixed by a social criterionbased on the average family income andability to pay in the area, even though thiscapacity to pay does not permit of re-covery of the total expenditure during theestimated amortization period. We alsothink that the deficit arising from thesenon-economic rates must be covered bythe Government, which should use for that

purpose funds intended for national sani-tation programs in rural areas. We believethat in order to finance the ten-year planfor rural water service through Alliance forProgress funds, the credit institutionsshould defray the entire cost, except for thecontributions that the communities them-selves can make. Finally, we think that, forthis financing, the minimum interest ratesand maximum terms that the banks areauthorized to agree to should apply, andthat in no case should the terms be shorterthan the applicable amortization period. Irepeat that I am submitting this proposalfor consideration by the Ministers.

Moreover, I think it timely to expressthe appreciation of the Government ofCosta Rica to the Alliance for Progress forthe aid that it has given the country inachieving, at the regional level, a projectfor rural aid based on a mobile health team,consisting of a general practitioner, a nurse,a public health physician, and a sanitaryinspector. The results obtained are evident;we are reaping the harvest of health educa-tion. During the few months in which thismobile plan has been in effect, it has beenable to reach sizeable sectors of the ruralpopulation, and when it is completely estab-lished, it will give medical aid to more than300,000 persons.

As proof to offer the economists in sup-port of our thesis that health problemsshould occupy first place in the plans foreconomic development of our countries, wemay note that in the communities there wassuch a desire to work along the lines indi-cated that the committees which we estab-lished, together with the inhabitants, un-dertook sanitation works, and even builtsecondary roads, before the health teamarrived. We emphasize the value of therural plan, but only when it is fostered byeducation in public health and when thecommunity is encouraged to aid, to theextent of its capabilities, in the solution of


the problems prevailing in the Latin Ameri-can countryside.

The status of nutrition is another yard-stick by which the gravity of the diseaseproblem may be measured. Examining ourstatistics, we can declare that as betweeneducation and health, health takes priority.Allow me to praise the educational traditionof my country. Nevertheless, in spite of theeducational level attained by Costa Rica,assessment of the nutrition problem showsthe indisputable priority that health hasover education. Here are statistics to proveit. Studying the great nutrition problem,which we must term the nutritional diseaseof our countries, we verified the fact that14 per cent of the population of Costa Ricais malnourished; in a community we sur-veyed, we discovered that 44.5 per cent ofthe inhabitants suffered from malnutritionof the first degree; 13.3 per cent are men-aced by malnutrition of the second degreeand 10.8 per cent by malnutrition of thethird degree. This shows that the firstproblem to solve is that of malnutrition.Its repercussion in the schools is wellknown; the fact that 30 per cent of thepupils in our classrooms repeat coursesmakes it evident. There come to our mindsthe words of the Secretary of Health andWelfare of Mexico in reference to malnu-trition as the cause of certain organic dam-age. So it is necessary to emphasize that itis useless to try to raise the educationallevel in our countries if we do not first pro-vide suitable health conditions for the in-habitants. This 30 per cent of repeaters inour schools clearly indicates the priority ofhealth problems. Faced by these 'impressivefigures we must realize that nutritionaldeficiency in our countries is a disease, ascourge, perhaps the greatest that is devas-tating us. It affects not only the rural areas,but it forms-and here I repeat what myfriend, Dr. Alvarez Amézquita said-abelt of misery around our urban communi-ties. In a survey made in our hospitals, 19per cent of the children from urban areas

enter with a diagnosis of malnutrition, ascompared with 4 or 10 per cent from therural communities; that is, malnutritionpervades the entire country. And since thechild who comes to the hospital to recoveroften dies, we thought it advisable to estab-lish, at strategic localities in the Republic,four or five centers as semi-hospitals orclinics for nutritional recovery. Our obliga-tion as Ministers, as men dedicated tohealth, is to see that children do not perishbecause of malnutrition, that they do notarrive at the last stage of malnutrition if wecan come to their aid in time.

As to the training of specialized person-nel, it can be said that, thanks to UNICEF,we are on the way to achieving training ofa national type that can certainly be con-verted into training at the regional level.We are interested, first of all, in trainingauxiliary personnel. Our countries, short ofspecialized personnel, cannot wait for thetime necessary to train specialists. The fewspecialists that we have need the aid ofauxiliary subprofessional personnel, espe-cially since it is necessary to educate fami-lies and bring basic ideas into the home inorder to combat nutritional disease. Wecannot wait until we train specialized per-sonnel, because hunger does not wait. Wewant to train professionals in their respec-tive specialties, with a total concept ofhealth. Because we desire to teach this con-cept of health, our work sometimes seemsto be frustrated, although in other localitieswe find understanding; but there is no doubtthat the cause is rooted in the lack of totaltraining of our professionals in healthmatters.

The contacts with the University and theearnest desire of the Ministry to establishan ever-stronger affiliation with it, have ledto the inclusion of preventive medicine inthe curriculum of our School of Medicinefor the five years of study. I believe thatthis is the greatest achievement of theSchool of Medicine of Costa Rica.

As for malaria and the communicable

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diseases, the country's statistics indicatethat an area of 31,000 km2 is now in astage of perfect consolidation, which leavesonly about 7,000 km2 to be tackled in orderto eradicate malaria from our country. Ourtechnical personnel from the Ministry de-clare that in 1965 malaria will have beeneradicated from Costa Rica.

I believe, Gentlemen, that this indis-putable victory, which we could boast ofnationally, will turn out to be a Pyrrhicvictory if our brothers, the Central Ameri-can countries, do not achieve similar results.I regret the malaria that harms El Salva-dor, Guatemala, Honduras, etc., as muchas the malaria that harms my own country.Since we, as men and brother Americans,want this victory to be total, we mustrecognize the regional character of certaincommunicable diseases. Malaria offers aperfect example of regional solidarity.

I wish that we could have a common ad-ministration and a common budget for thecountries that make up the region, so thatwe could raise our neighbors to the samelevel and proclaim this victory in a re-gional and definitive form in our area, andnot in a partial form, as perhaps will be thecase in Costa Rica in 1965.

As for tuberculosis, we may possibly bedeceiving ourselves. Our campaigns, wellplanned and positively pursued, are guiltynonetheless of excessive centralization, andit is possible that we still fail to recognizethe epidemiological factor. This is why wepropose, with the advice of the Pan Ameri-can Sanitary Bureau, to set up a pilot areato study this disease, with special attentionto epidemiology. We shall aid our doctorsand convince them that it is better to devotethemselves to preventive medicine than tocure tubercular lesions-often chronic anddefinitive-in hospitals.

We have dedicated ourselves to research,and we have established a virus laboratoryfor this purpose in Costa Rica. I should liketo make it clear that this word "research"is not mere show on our part, for in thislaboratory we do something more than ab-stract research; we study diseases that wedo not have the power to combat.

Our struggle against child mortality, ourfirm dedication to preschool-age children-since we think that the child who reachesthe classroom is a biological hero for havingsucceeded in surviving-forms a part of theenvironmental sanitation policy, which isadmittedly deficient. In this respect, wemust not forget that infant mortality oftenhas its source in enteric diseases. The viruslaboratory which I just referred to has asits first aim the investigation of the princi-pal enteric diseases.

As for vaccination, I accept with pleasurethe magnanimous idea of Dr. AlvarezAmézquita; to be able to count on a re-gional market in biological products wouldbe a positive step forward for our countries.As we lack appropriations for vaccine ma-terials, we must repeatedly thank-at leastwe in Costa Rica-the large countries,among them Mexico and the United Statesof America, for their generosity. But nocountry can live on the generosity of others,just as it cannot live in poverty. Conse-quently, the idea of manufacturing biologi-cal products on a regional basis for saleperiodically at low prices would permit usto proceed at the national level to the taskof vaccination; this is necessary to pre-vent many diseases which still affect ourcountries.

These are, in short, the chief aspects ofthe health problems of Costa Rica and thework that we are now doing to combatcertain diseases.

ADDRESS BY THE MINISTER OF PUBLIC HEALTH OF COLOMBIA

DR. JOSE FELIX PATINO


I brought a written report, in which theDelegation of Colombia presented somegeneral aspects of the public health problemin our country and also touched upon somepossible solutions of general application.However, these matters have already beentreated in large measure by other Ministersin a more brilliant form, and I have de-cided to abstain from reading this documentand to limit myself entirely to stressingsome of the points that have been discussedand to presenting certain aspects of thepublic health problem in Colombia whichare worth mentioning because of our specialexperience.

It is evident, as various speakers havesaid, that the mortality and morbidity ratesof the Latin American countries indicate afrankly inacceptable situation. You havespoken of infant mortality, about the fre-quency of infectious diseases, especially theenteric and respiratory infections, which arethe cause of the extremely high infant deathrates. Reference has been made to the ex-tremely bad environmental conditions, tomalnutrition, factors that result in a stateof physical and mental underdevelopmentand a low work output. All this we oughtto regard as grounds for achieving quicklythe solution we are seeking; for beginning toplan some concrete steps which will permitus to draw up realistic plans and to obtainimmediately effective solutions; for possiblythinking of drawing up somewhat more con-crete plans, more in; accord with reality,and avoiding insofar as possible the tragicparadox, which we often observe, of the

over-elaborate plan-one full of details ofan unattainable technical perfection, whichcan become an obstacle to the solution sourgently needed.

The Ministry of Public Health of Colom-bia considered it of interest to elaborate oncertain important points, as follows:

First: We think that, on the basis of theColombian experience, perhaps the mostimportant means for reaching a rapid solu-tion is the Ministry itself. The Latin Ameri-can countries, almost without exception, aregiven to frequent changes as one Adminis-tration succeeds another. Presidents change,and even during the tenure of a single one,the Ministry may change four or five times.

If the structure of the Ministry is basedon a technical plan, if the posts in thePublic Health Ministry are occupied byindividuals whose training and allegianceare entirely in the public health field, per-haps we can guarantee continuity of work.After promulgation of Law No. 19 of 1958,which gave authority to the Government ofColombia to reorganize Public Administra-tion, the decentralizing process, which theMinistry of Public Health had embarkedupon some years before through contractswith the departments or regions, was ac-celerated.

The reform brought about after thepromulgation of this law-just a few yearsago, that is-follows the plan of technicalcentralization and administrative decen-tralization. In effect, three levels have beenestablished: the central level of technicaldirection (plans, programs, standards,

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evaluation, supervision); the intermediateor administrative level, made up of thesectional or regional public health authori-ties; and the lower or executive level,composed of the agencies themselves.

The central level is-composed of a tech-nical and an administrative branch. Inaddition, there is a unit of supervision andexecutive coordination, and another unit ofplanning and evaluation.

It is important to note that the Ministryof Public Health now has completelytrained personnel and that only the Minis-ter himself is not a public health specialist.In the levels immediately below, all arepublic health specialists. We believe thatthis technical organization assures the con-tinuity of work and that this is one of thegoals to which the Latin American countriesshould aspire. The Minister may change,but if the organization of the Ministry isretained, the work will continue.

Second: For us, the training of personnelhas been a fundamental concern and animportant task. In 1948, with the adviceand economic aid of the United States ofAmerica, the Ministry created an institu-tion to take charge of training public healthpersonnel. This school, then called theHigher School of Hygiene, grew with theyears and in 1951 came to be part of theNational University. It is now called theSchool of Public Health; it receives impor-tant financial support from the Ministry,which is responsible for protecting it, en-couraging it, and keeping it free from polit-ical interests, within a purely academic

r4 framework.We believe that this coordination between

the Ministry of Public Health and theSchool of Public Health is a further guaran-tee that we shall obtain the personnel neces-sary to enable our health organizations tofunction effectively.

The allocation for the School occupies aplace of first rank in the Ministry of PublicHealth budget; it has suffered no decrease

in any previous budgetary period, but onthe contrary is being increased each year.

We have considered medical educationvery important in our program of personneltraining. The Government of Colombiaviews medical education, not as an isolatedfeature of education, but as a primary fac-tor in the promotion of health. The Minis-try of Public Health therefore demandsparticipation in, and responsibility for, themedical education programs.

We have achieved close coordination inthe medical education field in Colombiathrough the planning, establishment, anddevelopment of the Association of MedicalSchools, which has been functioning forfour years and grows stronger each year asthe result of the grants, collaboration, andsupport given by the Government. This, webelieve, is a very important instrument forbringing uniformity into medical educationand enabling the Public Health Ministry tocollaborate in a concerted effort to improvemedical standards in the country.

Third: Another effort to obtain closercoordination with medical education-which we present for your considerationbecause we deem it important-was to dele-gate to each of the schools of medicine re-sponsibility for administering one of theintegrated health districts.

Colombia's ten-year health plan calls forthe establishment of a series of integratedhealth districts, the organizations responsi-ble for comprehensive health care, bothpreventive and curative, for a certain num-ber of inhabitants-in our case, 100,000.The ten-year plan envisages the progressiveextension of these organizations throughoutthe country, and high priority has beengiven to the so-called "university districts."

In Colombia there are seven medicalschools, and a health district has beenturned over to each of them to administer.In this way the University has completecharge of administering the district, whilethe Ministry is limited to financing its


operations. Thus we give the medicalschools a new field of action, and theschools become thoroughly informed as tothe real medical problems of the country.I myself did not realize, even when I wasa university professor, that we were teach-ing medicine that was unrelated to the truesituation in Colombia. Only when I enteredthe Public Health Ministry did I realize wewere teaching medical theory often ex-tremely refined in exact surgical techniques,but perhaps of limited use in the country.How far our medical students were from areal knowledge of environmental sanitationand nutrition and the true health problemsof the country !

Through these university health districts,medical students will be able to study themedical problems of Colombia's differentgeographic regions, right on the spot ratherthan among patients in metropolitan hos-pitals.

So we have given these districts the high-est priority in our health plan. The firstwill be opened next month, and we hopethat within two years each of the medi-cal schools will be administering a healthdistrict.

Fourth: Another important matter wedeemed worthy of discussion is that of thepresence of authorized representatives ofthe public health authorities within the na-tional planning organizations. The organ-izations, councils, committees and boardsfor national planning are made up almostentirely of economists. All Governments, inour opinion, ought to make an effort toinclude on the national planning boards theMinister of Public Health, if possible, or atleast a high official of the Ministry, anindividual who is qualified to make deci-sions and has sufficient authority to influ-ence the formulation of these plans.

All of us agree, after hearing the state-ments previously made, that one cannotconceive of economic development withoutsocial progress as a base, and that the pro-

tection of the people, our chief source ofwealth, must not be forgotten. But what wesay here will be of no avail unless we drawfrom it an important conclusion: that wemust ask for the inclusion, in the nationalplanning committees or boards, of a highauthority from the ministries or secretariatsof public health.

To summarize, then, I propose considera-tion of the following concrete points:

1. To make a continent-wide effort, pref-erably through unified action, to achievethe organization of the ministries of publichealth on a technical basis, through appro-priate legislation.

2. To provide for the inclusion of theMinister of Public Health, the Secretary,or some high official, in the national plan-ning organizations.

3. To request a high priority for pro-grams of the ministries of health in thegeneral development programs of the coun-try and, of course, in the preparation ofnational budgets.

In Colombia we have found that a veryeffective way of winning Congressional sup-port has been to create committees, whichwe call liaison committees, made up ofCongressmen, usually doctors, who meetweekly in the Ministry to discuss healthproblems and the steps for solving them.This has been an expeditious means ofgaining in Congress quick approval of laws,which otherwise would have been quite diffi-cult to obtain. Even though my colleagues,the Ministers of the Hemisphere, are un-doubtedly skilled parliamentarians, I be-lieve that this method facilitates the taskconsiderably.

4. To plan the training of personnel notonly on the basis of sending individuals tomore developed countries on fellowships.Certainly this is quite important, but Iagree with our President that in the firstplace we should make better use of ourpersonnel and study, in cooperation with

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the medical, nursing, and public healthschools, the creation of national and re-gional centers where the greatest benefitcan be obtained and a greater number ofpeople trained. We should consider espe-cially the establishment of centers for train-ing auxiliary personnel-schools for nursingauxiliaries and for regional laboratory tech-nicians-in order to use, as our Presidenthas said, local personnel who speak thelocal language and who will be understoodby their own people. In this way we shallsolve the problem of keeping trained per-sonnel in the rural areas as well as in thelarge cities.

Finally, I believe that, in connection withthe recommendations that are to be made,

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this Task Force should express itself veryclearly on the plans and projects presentedto the Alliance for Progress and to the otherorganizations responsible for foreign aid.Although we certainly cannot envision for-eign. aid without technically-conceivedplans, it is equally certain that excessivedemands for detail in these plans can be-come an obstacle to speedy execution. I ama confirmed advocate of strictly technicalcriteria in plans, but I have observed thatthe requirements are often beyond thecapabilities of our countries. After all, ifwe were capable of drawing up plans withthis luxury of detail, our countries wouldnot be underdeveloped and perhaps weshould not need foreign aid.

ADDRESS BY THE MINISTER OF LABOR, SOCIAL WELFARE,AND PUBLIC HEALTH OF PANAMA

DR. BERNARDINO GONZALEZ RUIZ


The Republic of Panama comes to thismost important Meeting of Ministers ofHealth in the spirit of full cooperation andwith the desire to profit by most valuableexperiences. We bring to this convention, ofsuch great prestige, our greetings and ourbest wishes that the discussions may betranslated into victories and benefits for theAmerican peoples, positive declarations ofsolidarity, and guarantees of democracy.

The problem is how to carry out thisgigantic task of organizing health workamong the American peoples in such a waythat they may effectively participate in theeconomic revolution for the development ofa free America. The battle is on, and thePan American Sanitary Bureau, along withthe United Nations Children's Fund, havebeen and continue to be catalyzing forcesthat have helped produce unquestionableprogress. This struggle must go on, and newbattles must be waged, for the objectivesare clear and specific goals are attainablewithin more or less predictable periods oftime.

Disease is common in our America; thestate of physical and social well-being isextremely rare. If in other, already devel-oped, countries man has attained highlevels of production and consumption, itought to be possible to achieve this goal inour America, provided the means are madeavailable and plans are carried out to thenecessary extent and with the methodologyrequisite to a large health undertaking.

In order to use advantageously the capi-tal that we urgently need to invest in the

health field, we must rationalize the medico-health undertaking with a view to gettingthe best returns, in accord with the commonobjective. Consequently, health planning,which we now pursue so logically and withsuch urgency in each of our countries, oughtto be translated into extensive improvementof health in the Americas-with generaland specific, immediate and long-range ob-jectives-in which the great deficiencies ofcertain areas would receive the necessarypriority, and in which the common defi-ciencies could be made up and duplicationof effort and waste of resources avoided.

Health plans must be backed by avail-able resources, which taken as a whole canproduce a better yield in the undertakingthroughout the Hemisphere. No plan, nomatter how well conceived, can be put intopractice successfully if the investment capi-tal and the human capital are not soundlyplanned for. We are facing a difficult phasein the evolution of our sister Republics, anddifficult situations must be met with practi-cal, satisfactory decisions.

We have met here because, faced withthe problem of health planning, we areseeking financing facilities. With all thebacking that the Alliance for Progress canoffer us for financing many areas of ourhealth planning, supported directly or in-directly by capital investment, we believethat the rapid development of our institu-tions providing service, our programs, andour projects is going to call for so muchhuman capital skilled in the carrying out oflarge undertakings that we see ourselves in

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danger of changing course and taking al-ternative measures that will slow down thepace at which we proposed to achieve thedesired goals.

In other words, there is going to be ademand, the extent of which is difficult topredict just now, for professional and tech-nical personnel to give a strong initial driveto the health plans of our countries.

This is certainly more noticeable in thecountries of the Central American Isthmus,but it is easy to foresee it in the sister coun-tries of the Caribbean and South America.

We may raise the question as to whetherwe shall be able by ourselves to produce thequality and quantity of human capitalneeded for the medico-health undertakingin the Americas. Are there enough facilitiesin the Spanish language for teaching thediverse subjects that make up the publichealth field?

My country is very interested in thisaspect of the planning problem. Because ofPanama's privileged geographic position;because of the historic developments whichtook place there in the health field, whenthe heavy task of sanitation was carried outin the Isthmus to construct the PanamaCanal; because our country has been theheadquarters of organizations engaged inimportant medical research, such as theGorgas Memorial Institute of Tropical andPreventive Medicine and MARU, the Mid-dle America Research Unit of the U.S.National Institutes of Health; because ofthe presence of medical services of highquality in the Canal Zone; because of the

National Health Plan (1962-1970), a copyof which I have the privilege of handingeach of you; because of the collaborationoffered by the University of Panama, de-signed as a nucleus for the future PanAmerican University-in short, by reasonof all these valuable facilities in the field oftraining of personnel, my country will behappy to be the seat of a great institutionaleffort, at the disposal of all America, in thefield of public health and other fields ofmedical specialization.

Capital investment would undoubtedlycontribute to making development plans inthe health field more practical and applica-ble. In this effort we would all participate inproportion to our economic resources. Aplan of this nature would be of short range,but it would allow us to begin producing thepersonnel for the most pressing long-rangeneeds of the countries in order to go on pro-ducing slowly, but with effective continu-ity, that great technological capital thatAmerica requires urgently and extensivelyfor its health effort.

In closing, I should like to express to you,in the name of my Government, the mostsincere wishes that this high-level confer-ence in the health field will reach the de-sired objective of finding or pointing outthe paths we must follow to redeem theAmerican peoples from the lack of vitalitywhich, at this time of great social tribula-tion, weakens the establishment of demo-cratic ideals and social justice, to which thefree men of the Hemisphere aspire.

ADDRESS BY THE MINISTER OF HEALTH ANDSOCIAL WELFARE OF VENEZUELA

DR. ARNOLDO GABALDON


In commenting on the principal problemsaffecting health and the measures thatshould be taken pursuant to the objectivesof Punta del Este, I want to emphasize theneed to focus on the epidemiological objec-tives of the Charter, that is, to increase,during the decade, life expectancy at birthby a minimum of five years and to reducemortality among children under five yearsof age. This is important, because stress isoften placed on administrative objectiveswithout taking into account the fact thatwhat-we are really after is the reduction ofsome epidemiological problem.

When I took charge of the Ministry ofHealth and Social Welfare in 1959, I sug-gested that life expectancy at birth was theyardstick we should use to measure ourprogress. I did this in the report for thatyear presented to the National Congress.What had happened as a result of thisapproach from 1950 to 1958? We wereachieving an increase in life expectancy atbirth of six months per year of work, butwhat disturbed me was that many problemswere being approached in a vertical man-ner, with the object of giving very completecare to small sectors of the population,while large masses, especially in the ruralareas, were somewhat neglected. I stressedthe fact that it was necessary to replacethis vertical approach by a horizontal ap-proach that would afford less intense pro-tection but wider coverage.

I believe that, as a result of this approachand also the bettered economic situation of

workers and farmers that the country hasknown in recent years, appreciable changeshave been produced in life expectancy atbirth. From 1959 to 1961, the latest periodfor which figures are available, its increasewas 13 months per year of work. This con-firmed the fact that the first objective wehad set could be achieved and was not mereoptimism. In a study we made of two popu-lation samples, one rural and the otherurban, chosen because of their adequatedeath registration, the following figureswere obtained: in the rural sector, life ex-pectancy at birth was 53.6 years in 1958;in 1961 it rose to 59.2 years. In this briefperiod, then, the increase amounted to 5.6years. In the urban sector, life expectancyat birth was 63.3 years in 1958; in 1961 itwas 65.8 years. In this sector the increasewas six months per year of work, while inthe rural sector it was almost two years.However, in 1958 the rural population hada life expectancy almost 10 years less thanthat of the urban population, and in 1961this difference was only six years, whichshows that health conditions in the ruralenvironment have improved considerably.

In our search for a mortality rate thatwas easy to calculate and would serve as apractical guide, we found that the rate forthe group 1-4 years of age was of greatimportance, for it was the very one wherethe greatest difference showed up betweenthe countries of backward health status andthose of advanced health status. Here, too,we see that the improvement in health in

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the rural sector has been substantial in thelast four years. In 1958 the mortality rateof the group 1-4 years of age was 19.8; in1961 it was 11.9, or a reduction of 7.9. Inthe urban sector the rate of 7.4 in 1958dropped to 5.0 in 1961, a decrease of 2.4.These figures show that the rate of im-provement in health conditions of the ruralpopulation was much greater than that ofthe urban population; they also show thatit will be relatively easy to achieve the goalestablished in Punta del Este with respectto mortality among children under fiveyears of age.

But there is one point to which I want tocall special attention. The number of thosewho reach 15 years of age is of great im-portance in relation to the population inthe age group 15-64 years, or the economi-cally active group, although our life tablesindicate that a considerably smaller per-centage reach 15 years of age than in coun-tries of more advanced health status. As thebirth rates are almost double in our coun-tries, the number of children reaching theage of 15 is also almost double the onerecorded per 1,000 inhabitants of 15 to64 years in countries of advanced healthstatus. This means that the economicallyactive population of our countries supportsa scholastic burden almost double thatwhich the economically active populationin countries of more advanced health stand-ards have to support, while they have aper-capita income considerably higher thanours.

Moreover, the medically backward coun-tries have to create annually almost twiceas many job opportunities per 1,000 inhabi-tants of the age group 15-64 years as dothe medically advanced countries. This isa problem that I think we should examinecarefully, for it can have unfavorable re-percussions on future economic develop-ment; that is, we could come to a kind ofimpoverishment with a resulting decline inhealth conditions.

Among the administrative objectives inthe Charter of Punta del Este are some thathave the virtue of bringing with them epi-demiological gains. I think it important tokeep this in mind, for in planning one mustmake a distinction between administrativeand epidemiological objectives. Since plan-ning is governed by an economic criterionand gives great emphasis to purely ad-ministrative objectives, it can deflect usfrom the targets that we are really aimingat: a specific improvement in certain healthproblems.

From the economic viewpoint, I am inter-ested in the amount of national income de-voted to medical care in our countries. Inthe United States of America, 4 per centof the national income is devoted to medicalcare, preventive as well as curative, includ-ing that provided by both official agenciesand private practitioners. According to anestimate that we have made, 6 per cent ofthe national income in Venezuela is devotedto medical care.

As I am not an economist, I do not knowthe percentage of national income whichcountries now medically advanced werespending in the years from 1900 to 1910, theepoch corresponding, more or less, to themedical stage in which we live. I think thatit is important to ascertain this, for I be-lieve that with the skills now available, itis possible to work on health problems inour countries with relative speed and with-out spending a high proportion of the na-tional income. This is of some importance,for the time might come when, in the effortto improve our systems, we would divert tomedical care a share of the funds neededto improve the economy-the only meansby which we can maintain the benefits weseek for the future. This does not implythat we should subordinate man to theeconomy; what it means is that perhaps,with the methods we have today, properlyapplied, we can make improvements that


formerly might have required more timeand more money.

In order to establish the bases of thegoals we are aiming for and suitably meas-ure the advantages derived from our work,we must review our statistical problems.We undoubtedly need to improve birth anddeath registration. We must improve deathregistration so as to be able to knowwhether the figures we are obtaining in ourlife tables are realistic; we must makesome assessment of the available statistics,whether by the sampling technique or bythe use of statistical procedures to indicatehow far we can rely on available figures.

Recently, I have been stressing the needto establish a representative death registra-tion area by choosing a group of munici-palities where registration has been provento be reliable enough to serve as a basis forour statistical studies. I think it would beadvisable that, through the Pan AmericanSanitary Bureau, more time be given tothis type of study, since it is essential thateach country have confidence in its statis-tics. It is important that we not fail to heedour statistics, as frequently happens as aresult of deficiencies in the available data,and thus let our attention be diverted toadministrative objectives instead of theepidemiological objectives that we shouldpursue.

Moreover, in examining the high mor-tality rates for each age group, we find thatthere is a specific number of causes of deathwhich have produced the highest mortalityin each of these groups, aside from somediseases of a regional character, such asmalaria and others. But since we know thatexcessively high mortality in the selectedage groups is due to causes that werebrought under control in the medically ad-vanced countries, we can direct the healthmeasures against those diseases most sus-ceptible of control, so as to achieve in acomparatively short time a measurable and

favorable change in the death rates, whichis what we really want.

If we concentrate in this way on the mat-ter of removable causes, we must note thatcertain problems, susceptible of easy solu-tion, still cause some damage in our coun-tries. I refer in particular to smallpox; forthis disease we have a method of keepingthe population immune and hence free fromepidemic, a method which can be appliedeven by volunteers. Moreover, tetanus ininfants is still an important cause of deathduring the first week of life; perhaps thisis due to the fact that we do not use theservices of well-trained midwives.

I have mentioned these two diseases as anindication of what we could do at little costto reduce our health problems. But publichealth officials have been dominated by thecommunicable diseases, and we are ignoringother problems that do considerable dam-age, especially in the economically activepopulation. It is highly significant that insome of our countries homicides are thechief cause of death in the age group 20-40years; in others, they are the second cause.Accidents, too, especially with automobiles,are already appearing as the first cause ofdeath in this group, or the second cause insome countries. It is worth pointing outthat an automobile accident causes a majoreconomic loss, in that the person who dies insuch an accident has already reached aneconomic level higher than that of thepurely rural population.

Homicides and accidents are linked withalcoholism, and if, by virtue of the charac-teristics I referred to earlier, we have aneconomically active population with heavyresponsibility for the young and thus con-fronted with the need to create a largernumber of job opportunities, we must directpublic health work toward the protectionof this adult population, so that it can faceits problems of child care and advanceeconomically.

I think that it is impossible to say too

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much about the importance of directinghealth planning toward improvements inmorbidity and mortality rates, for I insistthat in the planning field, where economistsplay a major role, the objectives we arereally seeking can be forgotten, as has hap-pened in some cases. In Venezuela, for ex-ample, the number of hospital beds per1,000 population is lower than that in othercountries. Nevertheless, our mortality ratesare lower than in those countries. It wouldcost us a great deal of money to maintainas many hospital beds as the other coun-tries; without them, we still have betterhealth, though the medical care is inferior.Consequently, the goal must be, not to havea certain number of hospital beds per 1,000inhabitants, but rather to reach definiteepidemiological objectives by means ofspecific, direct measures against certaindiseases.

As for organization, in these last yearswe have had a small revolution. We haveseparated environmental sanitation fromthe other public health work, and have en-trusted these activities to two organizationsat the same hierarchical level, in order tobe able to give suitable attention to thedevelopment of environmental sanitationwork.

For a long time we have heard healthofficers speak about the need for makingenvironmental sanitation a basis for im-provement of health. Nevertheless, whenthe budgets are drawn up, allocations havenearly always been made at the expense ofenvironmental sanitation. The followingfigures indicate the change that has comeabout in Venezuela in this respect: from1945 to 1958, or a 13-year period, 160 ruralwater systems were built; from 1959 to1962, 136 were built. The figure for 1962was 82, and in accordance with the plan wehave submitted to the Inter-American De-velopment Bank, from which we received aloan, we shall be able to comply with theCharter of Punta del Este.

It is true that Venezuela still has a scat-tered rural population to which it will bedifficult to furnish water. But with the de-velopment work that we are carrying out,I think that the objectives of the Charterof Punta del Este can be achieved, so far asthe communities of from 100 to 5,000 in-habitants are concerned; this is the groupthat we are now concerned with in theMinistry of Health and Social Welfare.

Moreover, the National Institute of Sani-tation Works, which is concerned with com-munities of more than 5,000 inhabitants,has a program that will permit it also tocarry out what was agreed on at Punta delEste.

As for the personnel responsible for en-vironmental sanitation, there were 50 engi-neers in 1959 and 150 in 1962; that is, wehave tripled the number. These figures indi-cate the change of direction that has beenbrought about by this separation of activi-ties which, in reality, are quite differentfields and call for different types of uni-versity training.

Moreover, we are glad to confirm notonly the fact that the requirements of en-vironmental sanitation in rural areas callfor an organization of this type, but alsothat in the United States of America prob-lems springing from industrialization andurban development have led, according toreports I have read, to a proposal for asimilar form of organization.

On the other hand, we have taken arather important step in the organization ofthe medical care services which are in thecharge of the Ministry, the regional govern-ments, and some other organizations, bycreating, through agreements, cooperativepublic health services which integrate allthese activities into a single organization.They have a director appointed by theMinister and an executive board chosen bythe organizations participating in the co-operative program.

This service has already begun to operate


in several states, and there is reason to hopethat the Social Security Fund will later beassociated with it. Moreover, the Ministryof Public Works has asked that we, in theMinistry of Health and Social Welfare, takecharge of their medical care services. Thisshows that by means of such agreements itis possible to attain a unified organizationin countries where, because of certain fac-tors, it has hitherto been necessary to main-tain separate services. This is not a newidea; Mexico has had similar arrangementsfor many years, and perhaps other coun-tries have them.

With respect to control of communicablediseases, we know that we have made con-siderable advances in the case of malaria,which used to be the basic health problemof the country, since the area where thedisease has been eradicated was the firstto be registered by the Pan American Sani-tary Bureau. This area now consists of432,000 square kilometers and is third inextent after that of the United States ofAmerica and that of the Soviet Union. Onthe other hand, Chagas' disease affects theinhabitants in rural areas. Careful studieshave shown that damage to heart muscles,confirmed by electrocardiograms on infectedindividuals, is considerable, even in theearly ages of from 5 to 20 years. So, if weare to increase the efficiency of humanwork, it is very important to attack thisdisease, as we have attacked malaria. Fur-thermore, because of the available knowl-edge of suitable insecticides, we obviouslyhave powerful means for carrying our workto a successful conclusion.

Another disease worth mentioning, as anexample of the great progress we havemade, is gastroenteritis. With the introduc-tion of rehydration by tablets that can bedelivered to auxiliary personnel and tomothers, a radical change has come aboutin the number of deaths. In 1953 there were157 deaths from this disease; in 1958 thenumber decreased to 140, and in 1962 it

dropped to 75, thanks to the horizontalfocus of the campaign which I referred to.

We see clearly that it is possible to reducea serious mortality problem by satisfactorymethods of medical care. This by no meansindicates that we have reduced morbidity.We shall not succeed in this unless weachieve more effective fly control and havewater supply in the majority of our popula-tion centers.

With respect to malnutrition, there is nodoubt that its final solution will depend onan increase in agricultural production.Meanwhile, a 'product with a skim milkbase, which has been given to undernour-ished children, has appreciably contributedto reducing the mortality from this cause.

We have made some advances worthmentioning in the training of personnel, butwe should stress the fact that needs forhealth personnel must be taken care of tothe extent that the economic possibilities ofthe country permit, and we ought not tohave a greater number than that available,because we would have difficulty in main-taining such a number.

The Ministry has made agreements withall the universities so as to help financeimproved teaching of medicine and sanitaryengineering. The School of Public Healthis responsible for all postgraduate courses,and all these courses are financed by theMinistry of Health and Social Welfare.The School of Malariology has been en-larged so as to take care of the other activi-ties in environmental sanitation. As forauxiliary personnel, the use of appropriateand strict manuals has made it possible forindividuals with a sixth-grade education todo effective work, especially in simplifiedmedicine, which is the only type that canbe applied in rural areas remote fromcenters where there are medical services.

We have also considerably increased thenumber of fellowships. We had hoped thatthe expenses of the fellowship holders would

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be taken care of by the United StatesAgency for International Development oncethey had been accepted in North Americanuniversities. We did not succeed in makinga satisfactoiy arrangement in this respect,and last year 83 fellows, supported -by ourscarce dollars, studied in that country indifferent specialties of great interest forus. On the other hand, the fellowships ofthe Pan American Sanitary Bureau have

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been satisfactorily increasing in recentyears.

I believe that what I have said showsthat the objectives established in the Char-ter of Punta del Este are attainable, andthat what we have accomplished in Vene-zuela indicates that these objectives arefeasible and will be brought to reality inall our countries.

I hope that this comes about in 1971.

ADDRESS BY THE DEPUTY MINISTER OFPUBLIC HEALTH OF NICARAGUA

DR. CONSTANTINO MENDIETA RODRIGUEZ


I shall make a brief summary of thepressing public health needs of the Nica-raguan people which our Government isendeavoring to meet, although we shallpresent the technical problems to the ap-propriate committees at the suitable time.

With an area of 140,000 square kilo-meters and a population of 1,600,000, Nica-ragua forms a part of the Central Americanblock of countries. With a very few varia-tions of origin and development, its racial,cultural, and economic characteristics aresimilar to those of the other five Republics.It has more or less the same health prob-lems, as well as the same desire for pro-gressive development to improve the livingconditions of the people, Indo-Latin in ori-gin, for the most part.

Nicaragua is essentially an agriculturalcountry. A few years ago it started a fewsmall industries capable of producing forlocal consumption, thus opening up oppor-tunities for Central American commercewithin the plan for economic integration ofCentral America.

Population density averages 10 inhabi-tants per square kilometer. Nicaragua issituated between latitude 10° and 15 °

north. The prevailing religion is Catholi-cism, although there is religious freedom.Its natural resources are forest products,woods, gold and silver; there are deposits ofcopper, iron, lead, and other minerals. Theexport of cattle, coffee, and cotton is animportant source of national income. Fishabound.

Nicaragua is a democratic Republic withthree sources of authority: executive, legis-lative, and judicial. Recently, a change inthe Constitution has added a fourth-elec-toral power.

The economically active population ofboth sexes amounts to 31 per cent of thetotal-54 per cent of the masculine popula-tion and 8 per cent of the feminine.

Comparing fiscal receipts and the na-tional budgets for the years 1950-1951 withthe years 1962-1963, one notices a con-siderable increase. The first did not exceed67 million córdobas, while the secondamounted to 624 million.

Exports, as well as imports, have in-creased considerably in 10 years. In 1950the value of exports reached 24 millioncórdobas; in 1960, 72 million. The increasein imports was from 21 million to 67 millioncórdobas, respectively.

The percentage of illiterates is very high.Sixty-eight per cent of the people have notfinished a single year of primary education;29 per cent have had some years of primaryschooling. Two per cent have had someyears of secondary education, while 0.3per cent have taken university courses.

According to 1960 statistics, the principalcauses of death were the following: gastro-enteritis in infants, 13 per cent; gastro-enteritis in children, 11 per cent; accidents,6 per cent; malaria, 6 per cent; and influ-enza and pneumonia, 5 per cent.

Medical care and preventive medicine areseparate; this constitutes a serious problem

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for general health care. The hospitals of thecountry are subordinate to an autonomousorganization, the National Social WelfareBoard. There are 32 public and privatehospitals, with 3,872 beds, which gives anaverage of 2 beds per 1,000 inhabitants.There are 600 physicians in all the country;they are concentrated in the chief cities,such as Managua, León, and Granada,which have about 350 physicians. The restof the country, especially the vast Atlanticcoastal area, our largest and most moun-tainous area, lacks medical care. There are228 nurses in all, that is, 2 nurses per 10,000population.

The status of the health campaigns whichare being carried out by the Ministry ofPublic Health is as follows: The malariaeradication campaign is nearing completion,according to the latest reports. A zone con-taining 33 per cent of the population is inthe consolidation phase. The area where thecampaign is in the attack phase contains67 per cent of the inhabitants. It is believedthat the malaria eradication program willhave been completed by 1964, which willbe good news for the neighboring countries,because of the regional character of thisdisease. The only difficulty now being en-countered is mosquito resistance to insecti-cides; in the cotton areas, especially, itseems that spraying of insecticides has beencreating this resistance. A program ofchemotherapy is also being undertaken aspart of the effort to achieve complete eradi-cation of malaria.

Smallpox is now wholly eradicated in thecountry; for more than 30 years no casehas been recorded. However, vaccinationcontinues. In 1956, 14,108 persons werevaccinated; in 1957, 10,248; and in 1962,40,968. During the present year, 9,986 vac-cinations have been given to date.

A campaign for the investigation andtreatment of leprosy has been initiated,primarily in the Departments of Chinan-dega and León, the most affected areas.

We have an establishment for the hospital-ization of leprosy patients. The investiga-tion and treatment campaign is now beingconducted by a new unit under the directionof a leprologist.

Diphtheria-pertussis-tetanus (DPT) vac-cination is also being used. Under an agree-ment with the neighboring Republic ofCosta Rica, a campaign against rabies hasbeen conducted jointly with that country.Moreover, poliomyelitis vaccination andtyphoid fever vaccination are being carriedout. In 1962 the work included 87,680 TABvaccinations, 13,032 DPT vaccinations, and1,599 BCG vaccinations; in this campaign,5,018 tuberculin tests were made, with 29.13per cent positive, and 28,320 poliomyelitisvaccinations were given. In this connection,I should like to express the gratitude of theGovernment and the people of Nicaraguato the Republics of Brazil and Mexico fortheir generosity in furnishing us smallbox,poliomyelitis, and typhoid vaccines. We askthe Ministers of Health of these countries,present at this Meeting, to be kind enoughto convey the message to their Presidents.

The campaign against malnutrition hasdeveloped slowly for lack of suitable tech-nical personnel. My country, like those ofCentral America in general, must intensifyits nutrition campaign. Although we havethe essential resources for full nutrition ofthe individual, our people lack knowledgeof how to make the most of the land's re-sources. Consequently, we have establisheda pilot plan, covering the Departments ofCarazo, Rivas, Masaya, and Granada,where the majority of the rural populationlives-that is, 65 to 70 per cent of the totalpopulation. The Ministries of Public Educa-tion, Public Health, and Agriculture arecooperating in this pilot plan. Last week thefirst evaluation of the program's achieve-ments was made, with rather encouragingresults. Technical personnel teach childrenin the so-called "school gardens"; theyteach them what they ought to plant and


what the nutrition requirements are. In thisway, the education effort reaches the people.

On the basis of one year's experience, weshall soon be able to extend to the rest ofthe country this same system of interminis-terial cooperation for promotion of the peo-ple's health. We can supply the people withthe products of the land, to the end that ourfarmer will learn to sow, not only in orderto sell, but also to nourish himself.

The Ministry distributes milk, vitamins,and butter. In this milk distribution cam-paign, the children in all the schools andhealth centers were formerly given a glassof milk. The nutrition campaign is now be-ing approached on more technical grounds,and milk is being supplied only to thosewho really need it, that is, to those whoshow subnormal development.

We have also organized a maternal andchild health campaign, and we are begin-ning to give care to pregnant women, espe-cially the poor, with the aim of bringingabout better health conditions and greaterresistance to attacks of the external en-vironment, which are the bases for prolong-ing the life of the newborn and the child.This maternal and child health programprovides consultation and periodic ex-aminations for pregnant women and alsofurnishes nutrients such as vitamins andmilk.

We are also conducting a coordinatedprogram with the hospitals, whereby wetransfer mothers from the health centers tothe latter, in order that they may give birthin a hospital center, thereby avoiding therather high mortality recorded among thenewborn because of the lack of technicalaid during delivery. The mother returnsfrom the hospital to the health center;observation of the newborn continues there.

Among our human resources we have, ofcourse, professional health personnel: phy-sicians, nurses, health educators, healthvisitors, nursing auxiliaries, laboratorytechnicians, etc. However, the number that

we have does not fully satisfy our country'sneeds.

The nursing auxiliaries are simply healthvisitors, but they now complete their studywith courses for auxiliaries specialized inhospital nursing. According to the new plan,these courses, now lasting six months, willbe extended to nine months, three monthsbeing devoted exclusively to public healthaspects. Their purpose, especially in ruralareas, is to better prepare the auxiliarieswho visit homes to help the mother or thechild in case of need.

A course for health educators is nowbeing organized, since we have only 26 inthe country. We believe that the healthcampaign must inevitably be based on theeducation of the public. We are guided bythe belief that, from janitor to Minister,we must all be educators.

As for the technical structure of theMinistry, there is a trend toward convertingit into a purely technical organization inorder to prevent any delay or shifts in thehealth campaigns as the result of naturalchanges in Ministers or Government. Thisis also important so that the necessaryplanning may be carried out and the Minis-try may function in accordance with thetechniques established in each of the healthbranches. For the same reason, we aspire tothe establishment of a career service.

As we do not have a civil service, healthworkers will find an inducement in theknowledge that they can gradually obtainpromotions, with accompanying financialbenefits, in accordance with the senioritysystem that will shortly be established.

The health campaigns to which our Gov-ernment is striving to give priority becauseof the benefits they will bring to the people,call for analysis here, although you allknow them quite well. They are as follows:environmental sanitation, which includeshealth education, potable water supply,destruction of parasites, and constructionof privies; and the technically planned anti-

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tuberculosis campaign, which includes caseinvestigation, vaccination, and preventiveand curative chemotherapy.

In the governmental program of thePresident Elect, who will enter into officeon the first of next May, it is planned togive special emphasis to rural health cam-paigns. For many years we have been con-centrating on urban areas and neglecting therural zones which need attention more andwhere the great majority-65 to 70 percent-of the total population of the countrydwells.

As the first step for carrying out this plannext year, the areas with the largest numberof inhabitants have been selected; theyinclude the Departments of Granada, Rivas,Carazo, Masaya, and part of Managua(omitting the capital), where some 180,000inhabitants will be given preferentialattention.

s Special attention will be given to a trialpilot plan; the most extensive work possiblewill be carried out in environmental sanita-tion, nutrition, and investigation and con-trol of tuberculosis.

The urban population of Nicaragua isgrouped in 125 municipalities; only 40 ofthese have water systems (five more areunder construction), and 80 do not haveany piped water supply. Moreover, we have1,400 districts (comarcas), 3,304 villages,and 53,979 farms and ranches, containingsmall groups of people. As is clear, thepercentage of rural population which lackswater is very high. The small rural groupsobtain water from wells and rivers, andthese are sometimes quite far away.

The country has two organizations re-sponsible for solving the water supply prob-lems: the National Department of Munici-pal Services, which is subordinate to theMinistry of Development and Public Worksand conducts its activity in communities ofmore than 2,000 inhabitants; and the De-partment of Public Health EngineeringServices, subordinate to the Ministry of

Public Health, which works in communitiesof less than 2,000.

We are endeavoring to overcome theserious shortage of sanitary engineers, nowthat our country has engineering schools,where guidance is given to the young, andwe shall request scholarships to preparethese professionals. Our goal is to assign atleast one sanitary engineer to every regionof the country.

Only 32.4 per cent of the urban popula-tion now has water service; it may be saidthat the rural population, or most of thecountry, has no potable water service.

If one bears in mind the high rate ofinfant mortality caused by gastrointestinaldiseases which, even on the basis of defi-cient vital statistics, account for 20.8 percent of the total mortality, and the factthat the average of intestinal-parasitic in-festations and water-born infections is 85per cent, it is not difficult to understand thesignificance of this problem and our Gov-ernment's strong desire to give it priorityamong the campaigns of the Ministry ofPublic Health, in the hope that by 1973the goal of taking care of 70 per cent of theurban and 50 per cent of the rural popula-tion will have been reached.

The minimum annual cost of this cam-paign is estimated at $1,678,600 for theurban areas, including the water supply andsewerage service, with a per-capita cost of$25 for water and $10 for sewerage. Forthe rural sectors, the minimum annual costis $976,000, including water supply andexcreta disposal, with an average per-capitacost of $10 for water and $5 for excretadisposal. We intend each year to install10,000 privies and 10 small water systemsand to dig 120 wells, furnished with handpumps and the necessary sanitary pro-tection.

We have three factories producing con-crete privy slabs, at a cost of about 60 to70 córdobas each, or almost $10. Since thepublic was not financially able to buy them,


they were at first given free, but during thepilot campaign it has been noticed that thepeople do not appreciate things that aregiven away, and consequently a price of10 córdobas, to be paid within a year, hasbeen set.

Owing to Nicaragua's budgetary limita-tions, the Ministry of Public Health hasbeen allocated only 3.5 per cent of thecountry's total budget. Therefore, an in-crease of 10 million córdobas has been re-quested to begin this campaign. It is hopedthat the future President will push thiswork forward, as he has indicated he would,and fulfill our hope that public health willhave a place in the national budget secondonly to public education.

Within these budgetary limitations oncarrying out the environmental sanitationcampaign, an increase of $540,000 has beenrequested for next year. There is thereforea deficit of $436,000 in the estimated costwhich in 10 years will amount to $4,360,000.This we hope to obtain through the Alliancefor Progress. In making this request, weshall ask for facilities for obtaining sixrotary drills with a depth capacity of morethan 600 feet, since we have only two per-cussion drills, one assigned to municipal or-ganizations, and the other, of only 600-footcapacity, belonging to the Ministry ofPublic Health.

As I explained, the urban plan is theresponsibility of another body, which hasalready presented its requirements to theproper organization.

In the political plans for ministerial co-ordination to which I referred, the collabo-ration of the National Housing Instituteand of the banking institutions is contem-plated, for we understand that public healthdoes not consist solely in the absence ofdisease, but includes also: suitable housing,well located and in good condition; theability to obtain long-term building loans;opportunities for the acquisition of smallparcels of land of high fertility; and access

to small bank loans for agricultural pur-poses, so as to make the farmer independentof the large landholders and growers, andprovide him with facilities for planting andfor obtaining the means he needs to nourishhimself and his family.

We believe, as all have stated, that thesale of health is the best business transac-tion. I wish to emphasize, too, the ideaexpressed by other speakers, the hope thatwe shall succeed in changing the criterionof the directors of the Alliance for Progress,according to which only the economic, andnot the health, aspect is of importance. Wewould want them to understand that thebest source of a people's income is itshealth, for a sick people cannot progress,cannot produce, cannot build factories orindustries, or aspire to agricultural or totaldevelopment; a sick people will always bea very poor people.

It is often remarked that our farmers arefully active during the first hour of work,but an hour later are tired out and have tosit down to rest; this is due to the lack ofgood nutrition and protein foods.

Sugar usually furnishes our farmer'senergy, and corn is the basis of his diet.Before going out to work in the morning,he takes a cup of black coffee, with a fewbeans, and at noon he eats what he hasbrought with him-pinole and brown sugarcandy. This is the basic diet of our people.

The aspiration of people, of course, asDr. Alvarez Amézquita said, is full im-provement of health. And the wide gapbetween their present situation and theiraspiration-the concern of all of us and allour Governments-must be translated intoactivities leading to the betterment of thissituation.

The rancher and the cattleman are wellacquainted with the foods they must furnishto cows to make them give milk, and tohens to make them lay eggs. They alsoknow what vaccines they must give to cattleand hens, but they do not know what food

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Nicaragua 147

the farm laborer who works for them needsor what their own families need. For thisreason I, too, stress the need for a healtheducation campaign at all levels; that is, itshould not include solely the populationgroups of lower resources and lower skills,for as we know, even educated people maybe ignorant of health problems, despitetheir responsibility for caring for theirlaborers, even if only for the sake of greaterproduction.

I want to agree with what the Repre-sentatives of El Salvador and Hondurassaid regarding our earnest desire for promptaid from the Alliance for Progress; this helpmust be timely, and therefore ought to beimmediate. There is no land more fertilefor the planting of alien doctrines thanAmerica, which is struggling to keep themout. People who live poorly, who suffer fromhunger and illness, are very easy to con-quer. We ought to remedy this situation,capitalize our human factor. We should

recommend to the directors of the Alliancefor Progress that, if they are going to giveus their aid, they give it before very long-even if our countries do not satisfy all therequired conditions because we do not yethave the technical personnel needed tomeet them. We have not established statis-tics, but if help comes late, it will be un-necessary to do so.

On behalf of my Government, I shouldlike to thank, through Dr. Luther L. Terry,the President of the United States ofAmerica, John F. Kennedy, for his state-ment, as well as the Pan American SanitaryBureau, directed by the dynamic Dr. Hor-witz, for having initiated and organized thishighly important Meeting. We want torecommend to Dr. Horwitz that he expressthe wish of my people and, I think, that ofthe other American peoples, by suggestingto those responsible for the Alliance forProgress that they attend to our needspromptly.

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ANNEXES

Annex 1

OFFICERS OF THE MEETING AND

OF THE COMMITTEES

President of the Meeting:Dr. JosÉ ALVAREZ AMÉZQUITA Mexico

Vice-Presidents of the Meeting:Dr. LUTHER L. TERRY

Dr. PAULO PINHEIRO CHAGAS

Chairman of Committee I:Dr. ERNESTO R. LIMA

Vice-Chairmen of Committee I:Dr. ALFREDO LEONARDO BRAvo

Mr. FLORENTINO ALÉN

Rapporteurs of Committee I:Dr. FREDERICK J. VINTINNERDr. ADOLFO MORALES

Chairman of Committee II:Dr. ARNOLDO GABALDON

Vice-Chairmen of Committee II:Dr. JULIO C. BLAKSLEYDr. CARLOS QUIRÓS SALINAS

Rapporteurs of Committee II:Dr. FRANCISCO TOMRES BRACAMONTE

Dr. PAUL Q. PETERSON

Drafting Committee:Dr. MAX TERÁN VALLSDr. CHARLES L. WILLIAMS, JR.

Dr. AMADOR NEGHME

United States of AmericaBrazil

El Salvador

ChileArgentina

United States of AmericaUruguay

Venezuela

Argentina

Peru

BoliviaUnited States of America

Costa RicaUnited States of AmericaChile

151

Annex 2

LIST OF PARTICIPANTS

ArgentinaDr. Tiburcio Padilla

Minister of Social Welfare and PublicHealth

Dr. Julio C. BlaksleyChief Medical Officer, Department of Com-

municable DiseasesDr. Alfredo Rabinovich

Technical Secretary, Department of Com-municable Diseases

Dr. Alberto F. MondetSecretary of Public Health, Municipality

of Buenos AiresMr. Florentino Alén

Director General of Finances, Municipalityof Buenos Aires

BoliviaDr. Francisco Torres Bracamonte

Director of the National Public HealthService

Dr. Julio BustillosDirector of Normative Services, Ministry

of Public Health

BrazilDr. Paulo Pinheiro Chagas

Minister of HealthDr. Henrique Maia Penido

Superintendent, Special Public HealthService Foundation

Dr. Carlos Modesto de SouzaDirector General, National Department of

Rural Endemias

ChileMr. Benjamín Cid

Minister of Public HealthDr. Alfredo Leonardo Bravo

Chief, Technical Department, NationalHealth Service

Mr. Raúl Pefia LarraguibelEconomic Adviser, Ministry of Public

Health

Mr. Edgardo BoeningerEconomic Adviser, Budget Department,

Ministry of TreasuryDr. Amador Neghme

Secretary, School of Medicine, Universityof Chile, and Adviser to the NationalHealth Service

ColombiaDr. José Félix Patiño

Minister of Public HealthDr. Alberto Escobar

Secretary General, Ministry of PublicHealth

Dr. Alfonso MejíaChief, Executive Coordination Section,

Ministry of Public Health

Costa RicaDr. Max Terán Valls

Minister of Public HealthDr. Charles Chassoul

Chief, Department of Hospital Administra-tion

Dr. Claudio OrlichDirector General of Medical Care

Mr. Jorge CarballoManager, National Waterworks and

Sewerage Service

Dominican RepublicDr. Samuel Mendoza Moya

Secretary of State for Health and SocialWelfare

Dr. Miguel A. OrtegaPlanning Officer, Ministry of Health and

Social WelfareMr. Frank J. Pineyro

Executive Director, National PotableWater and Sewerage Institute

Dr. Luis Emilio MainardiEpidemiologist, Ministry of Health and

Social Welfare

152

cr.

List of Participants 153

EcuadorDr. Luis Pallares

Minister of Social Welfare, Labor, andHealth

Dr. Roberto Nevárez VásquezDirector General of Health

Mr. Gonzalo AyoraSpecial Assistant to the Director of the

Inter-American Cooperative PublicHealth Service

El SalvadorDr. Ernesto R. Lima

Minister of Public Health and SocialWelfare

Dr. Tomás Pineda MartínezDirector General of Health

Dr. Alberto Aguilar RivasSecretary-Coordinator, Technical and Plan-

ning Department Ministry of PublicHealth and Social Welfare

GuatemalaDr. Roberto Arroyave

Chief Surgeon, Director of Medical Edu-cation, Roosevelt Hospital (representingthe Minister of Public Health and SocialWelfare)

Dr. Carlos WaldheimChief, Department of Health Planning,

Ministry of Public Health and SocialWelfare

Mr. Ramiro BolafiosEconomist, General Secretariat, National

Council for Economic PlanningMr. José Antonio Palacios

Finance Counselor, Embassy of GuatemalaWashington, D. C.

HaitiDr. Louis Mars

Embassy of HaitiWashington, D. C.

Mr. Fern D. BaguidyAmbassador to the Organization of Ameri-

can StatesDr. Félix Colimon

Chief, Department of Outpatient ClinicsPublic Health Service

Dr. Jean BartholyAssistant Chief, Department of Medicine

General Hospital

HondurasDr. Carlos A. Javier

Undersecretary of State for Public Healthand Social Welfare

Dr. José Rodrigo Barahona CarrascoDirector General of Public Health

Mr. Gilberto BendafñaManager, National Autonomous Water-

works and Sewerage Service (SANAA)Dr. José M. Lagos Blanco

Chief of Administration, Ministry of Pub-lic Health

MexicoDr. José Alvarez Amézquita

Secretary of Health and WelfareDr. Miguel E. Bustamante

Undersecretary of HealthDr. Felipe García Sánchez

Technical Adviser, Ministry of Health andWelfare

Mr. Gerardo de IsolbiDirector General of Public Relations and

Press, Ministry of Health and WelfareLt. Col. Jesús Mercado Sixtos

Assistant to the Secretary of Health andWelfare

NicaraguaDr. Constantino Mendieta Rodríguez

Deputy Minister of Public HealthDr. Carlos H. Canales

Director of Local ServicesMinistry of Public Health

Dr. Orontes AvilésDirector of Administrative ServicesMinistry of Public Health

PanamaDr. Bernardino González Ruiz

Minister of Labor, Social Welfare, andPublic Health

Dr. Alberto E. CalvoDirector General of Public Health

154 Annex 2

ParaguayDr. Dionisio González Torres

Minister of Public Health and Social Wel-fare

Dr. Julio A. Martínez QuevedoDirector of Normative ServicesMinistry of Public Health and Social Wel-

fareDr. Roque J. Avila

Director of Medical Services for the Capital

PeruDr. Víctor Solano Castro, Brig. Gen.

Minister of Public Health and Social Wel-fare

Dr. Carlos Quirós SalinasDirector General of Health

Dr. David A. Tejada de RiveroChief, Planning OfficeMinistry of Public Health and Social Wel-

fareDr. C. Enrique Pitta López, Maj.

Assistant to the Minister

United States of AmericaDr. Luther L. Terry

Surgeon GeneralPublic Health Service

Dr. Leona BaumgartnerAssistant Administrator of Human Re-

sources and Social Development, Agencyfor International Development

Dr. M. Allen PondAssista.nt Surgeon General for PlansPublic Health Service

Dr. James WattChief, Division of International HealthPublic Health Service

Dr. Philip R. LeeDirector, Health Service DivisionOffice of Human Resources and Social

DevelopmentAgency for International Development

Mr. C. H. AtkinsChief Sanitary Engineering OfficerPublic Health Service

Dr. Charles L. Williams, Jr.Chief, Division of International RelationsPublic Health Service

Mr. Howard B. CalderwoodForeign Affairs OfficerOffice of International Economic and

Social AffairsDepartment of State

Dr. Paul Q. PetersonChief, Division of Community Health

ServicePublic Health Service

Dr. Arthur E. RikliMedical DirectorDivision of International HealthPublic Health Service

Dr. Edward O'RourkeDeputy Director, Health Service DivisionOffice of Human Resources and Social

DevelopmentAgency for Inteirnational Development

Dr. Frederick J. VintinnerRegional Health AdviserBureau for Latin American AffairsOffice of Human Resources and Social

DevelopmentAgency for International Development

UruguayDr. Aparicio Méndez

Minister of Public HealthDr. Adolfo Morales

Director, Division of HealthMinistry of Public Health

Dr. Mario ParejaDirector, Integral Public Health Center

Las Piedras

VenezuelaDr. Arnoldo Gabaldon

Minister of Health and Social WelfareDr. Alejandro Príncipe

Chief, Department of Demography andEpidemiology

Ministry of Health and Social WelfareDr. José Antonio Jove

Assistant EngineerDivision of Malariology and Environmen-

tal SanitationMinistry of Health and Social Welfare

Dr. Alfonso GiordanoSecretary-in-Charge, National Institute of

Sanitation Works

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List of Participants 155


Dr. José A. MoraSecretary General

Dr. Walter SedwitzAssistant Secretary for Economic and

Social AffairsDr. Jaime Posada

Assistant Secretary for Cultural, Scientific,and Informational Affairs

Alternates:

Dr. Francisco S. CéspedesDeputy Director, Department of Cultural

AffairsMr. Beryl Frank

Chief, Program of Social SecurityDepartment of Social Affairs

Mr. Alvaro MagañaAssistant Director, Department of Eco-

nomic AffairsMr. José Carlos Ruiz

Collaborator of the Assistant Secretary forCultural, Scientific, and InformationalAffairs

Mr. O. Howard Salzman, Jr.Chief, Advisory ServicesDepartment of Technical Cooperation

Coordinator:Mrs. Alzora H. Eldridge

Organizations Liaison Specialist

Inter-American Development BankMr. Felipe Herrera

PresidentMr. Humberto Olivero

Chief, Waterworks and Sewerage Services

Inter-American Child Institute (OAS)Dr. Victor Escardó y Anaya

Director General

United Nations Children's Fund(UNICEF)

Dr. Oscar Vargas MéndezDirector, Regional Office for the Americas

United Nations Economic Commissionfor Latin America (ECLA)Mr. Nicasio Perdomo

Deputy Chief, Washington Office

Annex 3

AGENDA

1. Plenary Sessions

1.1 Opening of the Meeting1.2 Election of President and two Vice-Presidents1.3 Designation of the representative of the Ministers to speak at the inaugural session1.4 Statement on organization and development of the Meeting by the Director of the Pan

American Sanitary Bureau, Dr. Abraham Horwitz1.5 Adoption of the Rules of Procedure (Document TFH/12)1.6 Adoption of the agenda (Document TFH/1)1.7 Adoption of the program of sessions (Document TFH/13)1.8 Establishment of the Drafting Committee1.9 Establishment and adoption of the terms of reference for committees1.10 Addresses by the Ministers of Health on the prevalent health problems of the Americas and

on policies for solving them in relation to the objectives of the Charter of Punta del Este1.11 Consideration and approval of the recommendations of the committees1.12 Approval and signature of the Final Report addressed to the Secretary General of the

Organization of American States and the Inter-American Economic and Social Council

2. Committee I

2.1 Election of Chairman, Vice-Chairman, and two Rapporteurs2.2 National planning for health (Document TFH/5)

2.2.1 Summary account of the present situation2.2.2 Planning units within the ministries of health2.2.3 Coordination with national planning bodies2.2.4 Improvement of collection, analysis, and reporting of basic data

2.3 Improvement of health services2.3.1 Summary account of the present situation2.3.2 Strengthening of organization and administration to bring about better utilization of

existing human and material resources2.3.3 Coordination of preventive and curative programs and services2.3.4 Long-term financing for construction and equipment of hospitals and other health

facilities2.4 Education and training of personnel (Document TFH/6)

2.4.1 Summary account of the present situation2.4.2 Summary statement on needs and resources2.4.3 Professional personnel2.4.4 Subprofessional personnel

2.5 Research (Document TFH/3)2.5.1 Summary account of the present situation2.5.2 Presentation of the status of the-program2.5.3 Recommendation on research needed to support health programs

156 Ai

Agenda 157

3. Committee II

3.1 Election of Chairman, Vice-Chairman, and two Rapporteurs3.2 Environmental health (Document TFH/2)

3.2.1 Review of the situation in the Americas3.2.2 Strengthening of environmental health services3.2.3 Assignment of responsibilities for urban and rural water supply and excreta disposal

system3.2.4 Administration of urban water and sewage systems3.2.5 Organization and administration of rural environmental health programs

3.2.5.1 Community organization and development3.2.6 Financing of urban and rural environmental health programs3.2.7 Hygiene of housing3.2.8 Water and air pollution control

3.3 Communicable diseases (Document TFH/11)3.3.1 Malaria eradication (Document TFH/7)

3.3.1.1 Report on status of program3.3.1.2 Technical problems3.3.1.3 Administrative problems3.3.1.4 Financing

3.3.2 Smallpox eradication (Document TFH/11)3.3.2.1 Review of the problem in the Americas3.3.2.2 Administrative obstacles to eradication

3.3.3 Control of tuberculosis (Document TFH/11)3.3.3.1 Summary account of the present situation3.3.3.2 Application of modern concepts and methods of control3.3.3.3 Extension and intensification of case-finding3.3.3.4 Ambulatory treatment3.3.3.5 Chemoprophylaxis and vaccination

3.4 Nutrition (Document TFH/10)3.4.1 General considerations3.4.2 Establishment of a national policy of food production and consumption as a function

of the nutritional requirements of the population3.4.3 Role of the ministry of health in formulating and implementing national food policies3.4.4 Nutrition programs of local health services3.4.5 Iodization of salt3.4.6 Production and utilization of low-cost protein preparations3.4.7 Programs to prevent loss of proteins through disease affecting livestock

3.5 Increase in life expectancy at birth by a minimum of five years during the present decade(Document TFH/8)

Annex 4

PROGRAM OF SESSIONS

Washington, D.C., 15-20 April 1963

9:00 a.m. FIRST PLENARY SESSION

1. Opening of the session

2. Election of President and two Vice-Presidents

3. Designation of the representative of the Ministersto speak at the inaugural session

4. Official opening by the President of the Meeting

5. Address by Dr. José A. Mora, Secretary General ofthe Organization of American States

6. Message of welcome from the President of theUnited States of America

7. Address by Mr. Felipe Herrera, President of theInter-American Development Bank

8. Address by Dr. José Alvarez Amézquita, Secretaryof Health and Welfare of Mexico, on behalf of theMinisters

3:15 p.m. SECOND PLENARY SESSION

1. Adoption of the Rules of Procedure

2. Election of the Chairmen of Committees I and II

3. Adoption of the agenda

4. Adoption of the program of sessions

5. Establishment of the Drafting Committee

6. Establishment and adoption of the terms of refer-ence for committees (item 1.9)

7. Statement on organization and development of theMeeting by the Director of the Pan American Sani-tary Bureau, Dr. Abraham Horwitz (item 1.4)

8. Addresses by the Ministers of Health on the preva-lent health problems of the Americas and on policiesfor solving them in relation to the objectives of theCharter of Punta del Este (item 1.10)

Tuesday, 16 9:00 a.m. THIRD PLENARY SESSION

1. Addresses by the Ministers of Health (item 1.10,continuation)

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Monday, 15

Program of Sessions 159

9:00 a.m. FIRST SESSION OF COMMITTEE I

1. Election of two Vice-Chairmen2. Appointment of two rapporteurs by the Chairman3. National planning for health (item 2.2)

SECOND SESSION OF COMMITTEE I

1. Improvement of health services (item 2.3)

9:00 a.m. FIRST SESSION OF COMMITTEE II

1. Election of two Vice-Chairmen2. Appointment of two rapporteurs by the Chairmen3. Environmental health (item 3.2)

2:45 p.m. FOURTH PLENARY SESSION1. Addresses by the Ministers of Health (item 1.10,

conclusion)

2:45 p.m. SECOND SESSION OF COMMITTEE II

1. Malaria eradication (item 3.3.1)2. Smallpox eradication (item 3.3.2)3. Control of tuberculosis (item 3.3.3)

6:00 p.m. DRAFTING COMMITTEE

Wednesday, 17 9:00 a.m. THiRD SESSION OF COMMITTEE I

1. Improvement of health services (item 2.3, continu-ation)

9:00 a.m. THrRD SESSION OF COMMITTEE II

1. Chagas' disease2. Nutrition (item 3.4)3. Increase in life expectancy at birth by a minimum

of five years during the present decade (item 3.5)

2:40 p.m. FOURTH SESSION OF COMMITTEE I

1. Improvement of health services (item 2.3, conclu-sion)

2. Education and training of personnel (item 2.4)3. Research (item 2.5)


Thursday, 18 11:00 a.m. FrFTH PLENARY SESSION

1. Presentation of the chapters of the Final Reportprepared by the Drafting Committee


4:15 p.m. SIXTH PLENARY SESSION

1. Consideration and approval of the recommendationsof Committees I and II (item 1.11)

160 Annex 4

Friday, 19

Saturday, 20

5:00 p.m. DRAFTING COMMITrEE

1. Preparation of definitive text of the Final Report

10:00 a.m. Visit of the Ministers of Health to Mr. John F. Ken-nedy, President of the United States of America (RoseGarden, White House)

2:50 p.m. SEVENTH PLENARY SESSION

1. Consideration and approval of the recommendationsof Committees I and II (item 1.11, conclusion)

4:20 p.m. CLOSING SESSION

1. Reading, approval, and signature of the Final Report

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TASK FORCE ON HEALTH AT THE MINISTERIAL LEVEL

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