DCD DIVISION OF COMMUNICABLE DISEASE CONTROL

WHO-EM/DCD/003/E/G Distribution: General

DCD DIVISION OF COMMUNICABLE DISEASE CONTROL

ANNUAL REPORT

2002

DCDDIVISIONOFCOMMUNICABLEDISEASECONTROL

ANNU AL REPORT 2002

WHO-EM/DCD/003/E/G Distribution:General Cairo2003

FOREWORD

4

INTRODUCTION

6

P ART 1 Communicable diseases in the EMR

8 Introduction10 Vaccine-preventablediseasesofchildhood10 Tuberculosis13 Malaria14 HIV/AIDSandsexuallytransmitteddiseases15 Emergingandepidemic-pronediseases16 Tropicalandzoonoticdiseases17

P ART 2 Challenges

20 Nationalcommitmentandleadership22 Strengtheninghealthsystems22 Ahugetask22 Buildingtrust24 Respondingtochange:thepublic-privatemix26

CONTENTS

Developinganintegratedapproach: cross-cuttingactivities30 Whyintegrationisneeded30 Focusingoncross-cuttingactivities32 Capacity-building32 Advocacy34 Infectioncontrol36 Containmentofanti-microbialresistance38 Managementofinsecticideresistance39 Operationalresearch40 Surveillanceforecasting&epidemicmanagement42 Partnershipforhealth44 Expandingintersectoralcollaboration44 Workingwithinternationalpartnerships48 Communityparticipation50 FacingrealitiesintheRegionandtheworld53 Complexemergencies53 Aborderlessworld58

P ART 3 Focusing on the p ossible

60

Communicablediseasesareresponsibleforthedeathsofanestimated1.3 millionpeopleintheEasternMediterraneanRegioneveryyear.Mostofthese deathscouldhavebeenpreventedwithproperutilizationoftheavailablecost- effectivepreventionandcontrolmeasures.Unfortunately,thisisnotthecase, andmillionsstilldieofcommunicablediseaseseveryyear. Itistruethatremarkablesuccessesincommunicablediseasescontrolhavebeenaccomplishedandthatthe generalpictureisquitepromising;however,thisisnotenough.Itisunacceptablethatchildrenarestilldying fromdiseasesforwhichaneffectiveandsafevaccineisavailable,suchasmeasles.Itisunacceptable,too, thatmorethan100000deathsoccurannuallyfromtuberculosis,whentreatmentundertheDOTSstrategy hasasuccessrateofmorethan90%.Sufferingfrommalariaandothervector-bornediseasescanbegreatly reducedbytheeffectiveuseofinsecticidetreatedbednets.Inaddition,thelivesofpeoplelivingwithHIV/AIDS canbeimprovedandextendedwiththeuseofantiretroviraltherapy. Toaddressthissituation,theRegionalOfficehaspromotedtheconceptofintegrateddiseasecontrol,inwhich betteruseofavailableresourcesandwidercoverageofinterventiontechniqueswillleadtoimprovedhealth forthepeopleoftheRegion.Theintegrateddiseasecontrolapproachwaspresentedinatechnicalpaperto theRegionalCommitteefortheEasternMediterraneanin2002,andtheconceptgeneratedagreatwaveof enthusiasm.ThiswasthebeginningofneweraofcommunicablediseasescontrolintheRegion.However, thewayisnotyetclear.Withoutathoroughunderstandingofthemanychallengesfacingusandtheobstacles lyingahead,wemaynotbeabletoprogressatthepacewewouldlike. Thisyear’sAnnualReportoftheDivisionofCommunicableDiseaseControlisatransparentlookatthe difficultieswemustovercomeandthechallengeswefaceindoingso.Itisnotareportaboutthedivisional achievementsofthepastyear;onthecontrary,itisapragmaticanalysisofthemagnitudeoftheproblems

weareattemptingtoresolveandthecomplexitiesinherentinimplementinganewapproachinanever- changingenvironment.ItismywishthatallthoseworkingforandwiththeDivisionofCommunicableDisease ControlintheRegionwillsucceedintheireffortstomovecommunicablediseasepreventionandcontrolinto aneweraofprogressivesuccesswitheveryadvancingyear. 45

HusseinA.GazairyMD,FRCS RegionalDirectorfortheEasternMediterranean

FOREWORD

Failuretoachievethetargetscannotbeexplainedonlybyfailureofthemethodologyusedfortacklingthe problem;itliesalsoinfailuretofullycomprehendtheproblem. ThechallengesfacingcommunicablediseasescontrolvarygreatlyamongthedifferentcountriesoftheRegion. Thesechallengesincludelackofnationalpoliticalcommitmentandleadershiptosupportthecontrolprogrammes, weakhealthsystemswithinequitabledistributionofhealthservices,loweducationalandawarenesslevels amongthegeneralpopulation,ineffectiveandunplanneddecentralization,fragmentationofresources,"brain drain",poverty,politicalinstabilityandcivilstrife.InmanycountriesoftheRegion,healthsystemsareill equippedtocopewiththecurrentorfuturedemandsforcommunicablediseasescontrol.Moreover,while institutionalproblemswhichcanlimitperformanceofthedifferentcommunicablediseasescontrolprogrammes arecommon,theyhavebeenlargelyneglectedbythehealthauthoritiesinthepast. Inourbattleagainstcommunicablediseases,wemustconstantlystriveforbetterunderstandingofthefactors thataffectcommunicablediseasecontrol.Thisisnotaneasytask.Itrequiresthoroughanalysisofthe strengths,weaknessesandchallengesfacingthecontrolprogrammesineachcountryintheRegion.This reportdrawsattentiontothecomplexityofthechallengesfacingthecommunicablediseasescontrol programmesinthedifferentcountriesoftheRegion.Itexplainshowlessonslearnedfrompastexperiences failurescanguideamoretargetedandpragmaticapproachtocurrentandemergingchallengesandoffers strategicdirectionsfortacklingthesechallenges.

Ourfightagainstcommunicablediseasesisfarfromover.Communicable diseasesarestillthemajorcauseofprematuredeathinthispartoftheworld. Theyareresponsibleforone-thirdoftheannualdeathsintheRegionandfor 32%ofthediseaseburdenasmeasuredindisability-adjustedlifeyears. Moreover,communicablediseasesareamajorcauseofpoverty,under- developmentandhumansuffering. Thedevelopmentofeffectivetreatmentandvaccinesagainstpriority communicablediseasesduringthe20thcenturyshouldhavemadeasubstantialimpactonthesediseases. However,thisdidnotoccur.Theeuphoriawhicharoseduringthesmallpoxeradicationeragraduallydwindled withthefailuretoachievemalariaeradication.Inthenextera,newcommunicablediseasesemerged,such asAIDS,ebolaandmorerecently,SARS,whileotherswhichhadbeenlargelyforgotten,suchastuberculosis, malariaanddenguefever,re-emergedasapublichealththreat. Inourannualreportoflastyear,wefocusedon thesituationofcommunicablediseasesinthe EasternMediterraneanRegion.Welooked extensivelyatthediseaseburdeningeneraland specificdiseasesinparticular.Wediscussed generalpreventionandcontrolmeasures,with examplesofsuccessesandpitfalls.Wealso admittedthatwehavenotyetachievedallthat ispossibleandthatwearestillfarfromreaching ouraimtodeliverthepeoplefromavoidable sufferingandtosavetheirlovedonesfrom preventabledeath.Inthesamereport,we proposedanewapproach,the"integratedapproach",toscaleupcontrolactivitiesanddevelopanessential packageofservicesthatcanbedeliveredattheperipheryunderwhateverconditions.Wearenowonthe way. Inthisyear’sannualreport,weoutlinethechallengesfacedinourwork.Itisclearthateventhebestapproach willnotproducetheexpectedresultsunlessittakesintoaccounttheenvironmentinwhichitwillbeused.

DrZuhairHallaj Director,CommunicableDiseaseControl

INTRODUCTION

Communicablediseases 32% Maternal conditions3% Prenatal Conditions8% Nutritional deficiencies4% Noncommunicable diseases42%

Injuries 11%

P ART 1 Communicable Diseases in the Eastern Mediterranean R egion

thegapbetweenwhatisachievableandwhatis beingachieved Introduction Vaccine-preventablediseasesofchildhood Tuberculosis Malaria HIV/AIDSandsexuallytransmitteddiseases Emergingandepidemic-pronediseases Tropicalandzoonoticdiseases

INTR ODUCTION

ForthecommonestcommunicablediseasesintheRegion,effectivestrategiesfor treatmentand/orpreventionhavebeenestablished.Nevertheless,morethanoneand aquartermillionpeopleintheRegioncontinuetodieeachyearofcommunicable diseases.Insomecountries,diseasecontrolprogrammeshaveanationalreachand targetsfortreatmentorimmunizationarebeingmet;inothers,thereisavastgap betweenthesetargetsandwhatisactuallyachieved.Asmostcontrolstrategiesfocus onasinglediseaseorgroupofdiseases,wecanbeginbylookingathowthese programmesoperateintheRegion,andbrieflyindicatewhythetargetsarenotbeing met.InPart2,wetakeabroaderviewandlookatthecommonchallengesfacingall communicablediseases.

V ACCINE-PREVENT ABLE DISEASES OF CHILDHOOD

TheExpandedProgrammeofImmunization(EPI),supportedbyWHOandothermultilateral agencies,isadministeredbyministriesofhealthinallcountriesoftheRegion.Yet,in spiteofyearsofeffort,almost3millioninfantsintheRegionstilllacktheirbasic immunizationseachyear.WhilesomecountriesintheRegionhaveachievedacoverage ofover90%forthecombinedtheDPT3antigen(fordiphtheria,pertussisandtetanus), othershoveraround50%,andthelowestis18%.IntheRegionoverall,forthepast decade,childhoodimmunizationlevelshavestagnatedataround80%,andonlyhalf ofallpregnantmothersareimmunizedagainsttetanus.

Morethanoneand aquartermillion peopleintheRegion continuetodieeach yearof communicable diseases. IntheRegionoverall, forthepastdecade, childhood immunizationlevels havestagnatedat around80%,and onlyhalfofall pregnantmothers areimmunized againsttetanus.

Progressin immunizationis particularlyslowin sevencountries whichaccountfor morethanhalfofthe childreninthe Region. WithinEPI,measles hasbeentargeted forregional elimintationby 2010;yetthere arestillaround 40000casesof measleseveryyear intheRegion,and reported immunization coveragevaries nationallyfrom99% to35%. 10

PART1CommunicableDiseasesintheEasternMediterraneanRegion ...Vaccinenotincludedincountry’sschedule *Datafrom2001 **Datafrom2000 Datasource:WHO/UNICEFjointform2002

COMMUNIC ABLE DISEASES IN THE EASTERN MEDITERRANEAN REGION the gap between what is achievable and what is being achieved

COUNTRYBCGDPT3OPV3MCV1HBV3TT2+HIB3 Afghanistan(AFG)59.2046.7048.2043.70...37.00... Bahrain(BAH)20.0098.1097.9099.9098.4058.5098.00 Cyprus*(CYP)...97.5097.5085.5089.00...... Djibouti(DJI)52.0461.8061.7762.07...33.46... Egypt(EGY)98.2096.8096.8096.9096.8069.60... Iran,IslamicRepublicof(IRN)100.0099.00100.0096.0099.0035.00... Iraq**(IRQ)85.0074.0082.0080.0064.0082.00... Jordan(JOR)28.8095.0095.0095.0095.0036.0095.00 Kuwait**(KUW)...98.0098.0099.00100.00...... Lebanon(LEB)...92.4092.4096.0088.00...... LibyanArabJamahiriya*(LIB)99.0093.5093.5090.8090.80...... Morocco(MOR)90.0094.5095.0096.0092.0026.00... Oman(OMA)98.0898.6099.9999.0099.9944.6697.00 Pakistan(PAK)81.9068.5070.7063.0018.0055.70... Palestine(PAL)95.6096.5096.5093.7091.7030.00... Qatar(QAT)100.0096.0096.00100.0098.00...96.00 SaudiArabia(SAA)97.8094.7094.7096.7097.30...91.00 Somalia(SOM)60.0040.0040.0045.00...60.00... Sudan(SUD)68.3064.2064.3061.80...34.50... SyrianArabRepublic(SYR)100.0099.0099.0098.0098.0040.0099.00 Tunisia(TUN)97.0096.0096.0094.0094.00...... UnitedArabEmirates(UAE)98.0094.0094.0094.0092.00...94.00 UNRWA99.8099.0099.0097.3099.0098.70... Yemen,Republicof(YEM)74.0069.0069.0065.0034.0039.00... Reportedcountries’bestestimatesforroutineimmunizationcoverage(%)2002

Progressinimmunizationisparticularlyslowinsevencountrieswhichaccount formorethanhalfofthechildrenintheRegion.Mostofthesecountriesarepoor, someareinastateofcomplexemergencywithonlyrudimentaryhealthservices. Animmunizationservicedesignedtoreachallchildrenisacomplexoperation.It requiresahugesupplyofvaccinesandinjectionmaterials,trainedstafftoadminister thevaccinessafely,anefficientrecordkeepingsystem,andvehiclesandcold-chain equipmenttodelivervaccinestothemostdistantprimaryhealthcarecentersina timelyfashion.Eveninwhatatfirstsightappearstobeaneffectivenationalhealth system,theserequirementsmaynotbemetbecauseofpoormanagementandlack ofcommitmenttothevitaltaskofchildimmunization. WithinEPI,measleshasbeentargetedforregionaleliminationby2010;yetthere arestillaround40000casesofmeasleseveryyearintheRegion,andreported immunizationcoveragevariesnationallyfrom99%to35%.Neonataltetanusisalso targetedforelimination,definedaslessthanonenewcaseayearper1000livebirths ineachadministrativedistrictofthecountry.Yet,sevenofthepoorestcountriesinthe Regionhavenotachievedthistarget.Intheseandseveralothercountries,vertical programmesincludingpolioarecompetingfortheservicesofweakhealthsystems. Atthesametime,insomecountriesintheRegionnewlife-savingvaccineshave becomeavailable:thehepatitisBvaccineandtheHibvaccinetopreventhaemophilus influenzatypeb,themostimportantcauseofpneumoniaandmeningitisamongunder fives.Butthesevaccinesarecostly,andcanonlybeintroducedintocountriesthat alreadyhavegoodimmunizationcoverage.Manycountriesclearlydonothavesufficient capacityorcommitmenttoachievethegoalssetforcoverageofexistingvaccines, letalonenewones.

TUBER CULOSIS

DOTS(directlyobservedtreatment,short-course)isnowthenationalpolicyfor tuberculosiscontrolinallcountriesoftheRegion,providingfreediagnosisandtreatment. ThetreatmentsuccessrateintheRegionis81%,approachingtheglobaltargetof 85%.Nineteenofthe23countrieshadachievedDOTSALLOVERbytheendof2002, withDOTSavailablethroughoutthecountry. Yet,evenacountrythathasachievedDOTSALLOVERwillnotbeabletoreachevery singlepersonwhohastuberculosis.ThemaintasknowistoexpandDOTStoreach allthosesuspectedofhavingthedisease.For,atpresent,onlyaboutonequarterof thepeopleestimatedtohavetuberculosisarereceivingtreatment.Unlessserious effortsaremade,thepercentageoftreatedcasesintheRegionwillbarelyreach35% by2005,halftheglobaltargetof70%. SlowexpansionofDOTScoverageoccursmainlyintwocountries:inPakistanandin war-tornAfghanistan.InmanyothercountriesoftheRegion,casedetectionalsoneeds tobeimproved.OtherpartsoftheDOTSprogrammealsoneedtobeupgraded, especiallysurveillance,laboratoryservicesfordiagnosis,andmonitoringdrugresistance. Itisalsoessentialfornationalprogrammestocollaboratewiththeprivatesector providers,whotreatanincreasingnumberoftuberculosispatients.

Neonataltetanusis alsotargetedfor elimination,defined aslessthanone newcaseayearper 1000livebirthsin eachadministrative districtofthe country.

DOTS(directly observedtreatment, short-course)isnow thenationalpolicy fortuberculosis controlinall countriesofthe Region. Nineteenofthe23 countrieshad achievedDOTSALL OVERbytheendof 2002. Themaintasknow istoexpandDOTS toreachallthose suspectedofhaving thedisease.For,at present,onlyabout onequarterofthe peopleestimatedto havetuberculosis arereceiving treatment.Unless seriouseffortsare made,the percentageof treatedcasesinthe Regionwillbarely reach35%by2005, halftheglobaltarget of70%. 1213

PART1CommunicableDiseasesintheEasternMediterraneanRegion Casedetectionrate%

Treatment successrate

%

Treatmentsuccessrate2001versuscasedetectionrate2002

(153)LEB OMA (107)

MOR

TUN JORCYP IRNBAHEGY SYR YEMSUD

SOMIRQAFG REGION PAKUAE SAALIBQAT (101)

100 90 80 70 60 50 40 30 20 10 0 0102030405060708090100

KUWDJI

MALARIA

ThemajorityofthepeopleoftheRegion(around72%)liveincountriesinwhichmalaria iseffectivelycontrolled.However,naturalconditionsthroughouttheRegionarefavourable tothesurvivalofthemosquitovectors.Thus,evencountrieswithnocurrenttransmission needtobecommittedtomaintainingagoodsurveillancesystemtopreventthe reintroductionofthediseasebyinfectedmigrantsortravellers. FivecountriesintheRegion–Afghanistan,Djibouti,Somalia,SudanandYemen– contribute90%oftheRegion’sestimated15millioncasesayear.Currentlyavailable treatmentinthehomeorthehealthcentrecancontrolmorbidityandmortality,especially amongchildren,butitneedstobeprovidedwithin24hoursoftheonsetofsymptoms. Forpregnantwomen,effectiveprophylacticdrugsgiveninthesecondandthirdtrimester canpreventmalariaand,withit,maternalanaemia.Anaemiaincreasestheriskof givingbirthtolow-birth-weightinfants,whohaveahighriskofdeathinthefirstyear oflife. However,accesstoprophylacticandcurativedrugsislimitedinareaswhichdonot havefunctioninghealthservices,andhealthfacilitiesmaybeshortofdrugs.Thus,in manyareas,patientshavenochoicebuttobuysubstandardorinappropriatedrugs frompharmaciesoruntrainedhealthproviders.Thissituationhastenstheproliferation ofdrug-resistantplasmodia.Moreover,onlyasmallproportionofthoseintheRegion whoneedinsecticide-impregnatedbednetsareabletoobtainthem.Overall,integrated vectorcontrolstrategieshaveyettobeputintopracticeinmostaffectedareas.

HIV/AIDS AND SE XUALLY TRANSMITTED DISEASES

HIV/AIDSisgrowingrapidlyintheRegion,withathreefoldincreaseinestimatedcases between1999and2001,toacurrentestimateofaround70000.However,only10597 caseshadactuallybeenreportedintheRegionuntiltheyear2000;in2000fewer caseswerereportedthanin1999.Becauseofthelackofnationalcommitmenttothis diseaseproblem,fewcountriesoftheRegionhaveestablishedcontrolprogrammes. FewofthoselivingwithHIV/AIDSarebeinggiventreatmentorsensitivecounselling, whichinindustrializedcountrieshavebeenshowntoincreasetheirqualityoflifeand abilitytofunctioneffectivelyinsociety.FewofthemillionsofpeopleintheRegionwith

Fivecountriesinthe Region– Afghanistan, Djibouti,Somalia, SudanandYemen– contribute90%of theRegion’s estimated15million casesayear. Currentlyavailable treatmentinthe homeorthehealth centrecancontrol morbidityand mortality,especially amongchildren,but itneedstobe providedwithin24 hoursoftheonset ofsymptoms.

HIV/AIDSisgrowing rapidlyintheRegion, withathree-fold increasein estimatedcases between1999and 2001,toacurrent estimateofaround 70000. Becauseofthe unwillingnessto engageinpublic discussionof sexuallyrelated issues,preventive strategiesareonly slowlybeing developedandthe publicintheRegion remainunawareof theriskofHIV/AIDS. MalariastatusofcountriesintheRegion2002

Transmission-free Eliminationunderway Lowtomoderateendemicity Highendemicity 14

PART1CommunicableDiseasesintheEasternMediterraneanRegion

curablesexuallytransmitteddiseaseshavereceivedtreatment,althoughsexually transmitteddiseasesareknowntobeariskfactorforHIVtransmission.Becauseof theunwillingnesstoengageinpublicdiscussionofsexuallyrelatedissues,preventive strategiesareonlyslowlybeingdevelopedandthepublicintheRegionremainunaware oftheriskofHIV/AIDS.Theproblemofunsafeinjectionsandpoorlyprotectedblood suppliesareonlygraduallybeingaddressed,yetthesearelikelytoberesponsiblefor anincreasingproportionofHIVinfections.

EMER GING AND EPIDEMIC-PR ONE DISEASES

Anumberofcommunicablediseaseshavethepotentialtodeveloprapidlyintoepidemics thatcouldthreatenthehealthandlivesofmillions.Epidemic-pronediseasesinthe Regionincludemeningitis,diarrhoealdiseases(includingcholera)andhepatitis.Also havingthecapacitytodevelopintoepidemicsaretheemergingviralhaemorrhagic feverssuchasCrimean-CongohaemorrhagicfeverandRiftValleyfever,whicharelittle knowntohealthprovidersandusuallyconfinedtorestrictedareas. Forthecontrolofalltheseepidemic-pronediseases,aneffectivediseasesurveillance systemisespeciallyimportant.Attheregionalandcountrylevel,asystemfor preparednessandresponse,supportedbyaspecificbudget,drugs,equipmentand trainedresponseteamsisalsorequired.Theneedisespeciallyacuteinpoorcountries oftheRegion,whichusuallyhavemanyepidemic-pronediseases,aswellasahigh burdenofendemicdiseases.Thesecountriesrequireexternalresourcesfromorganizations suchasWHOtoestablishandmaintainemergencyresponsesystemstopreventand containepidemicswithinthecountry,andpreventthemfromspreadingbeyondtheir borders.

TR OPICAL AND Z OONOTIC DISEASES

Anumberofdiseasesthatarenotusuallyfatalseriouslydisabletheirvictims,resulting inhardshipandeconomiclossesforallhouseholdmembers.Asmanyofthesediseases arealsohighlyfocal,andenvironmentallyrelated,theyalsohaveaseriousimpacton wholecommunities.Yettheyareoftenneglectedbythehealthcaresystem,asthey occurinremoteareas. Leishmaniasisisaneglecteddiseasewhichtodayisagreaterthreattopeopleofthe Regionthaneverbefore.Itoccursintwomainforms:cutaneousleishmaniasis,which isnotusuallyfatalandisthemostcommonandwidespread,andvisceralleishmaniasis, whichisusuallyfatalwithin2yearsifitisnottreated.Bothformsaredifficulttocontrol becauseoftheircomplexecologywhichincludesmanyreservoirhosts.Sprayingis expensiveandunsustainableinthelongtermandthedrugsavailablefortreatment oftenhaveseriousside-effectsorhavedevelopedresistance.Thuscontroldepends onamixofsurveillance,earlydetection,treatmentandprevention. Thepublichealthsignificanceofschistosomiasishasbeenreducedsignificantlyin somecountrieswiththeintroductionofahighlyeffectivesingledoseoraldrug, praziquantel.Jordan,theIslamicRepublicofIran,MoroccoandTunisia,areaimingto achievetheeliminationofindigenoustransmission.InEgypt,theNationalSchistosomiasis ControlProgrammehasbeenresponsibleforamarkeddeclineinthelevelofinfection inthatcountry.

Forthecontrolofall theseepidemic- pronediseases,an effectivedisease surveillancesystem isespecially important.

Leishmaniasisisa neglecteddisease whichtodayisa greaterthreatto peopleoftheRegion thaneverbefore. Thepublichealth significanceof schistosomiasishas beenreduced significantlyinsome countrieswiththe introductionofa highlyeffective singledoseoral drug,praziquantel. 1617

PART1CommunicableDiseasesintheEasternMediterraneanRegion

However,inothercountries,wherethesituationhasremainedstableordeteriorated, nonationalstrategyhasbeendeveloped. Anumberofdiseaseshavebeentargetedforglobaleradication(followingtheprecedent ofsmallpoxin1976),orelimination,astateinwhichthediseaseisnolongerrecognized asapublichealthproblem.Dracunculiasis(guinea-wormdisease)hasbeenthetarget ofaglobaleradicationprogrammesincetheearly1980s.Seventy-fivepercent(75%) oftheremainingcases,worldwide,arefoundinSudan,mainlyinthesouthofthe country.Here,dracunculiasiseradicationfacesproblemssharedwithmanyother diseaseswhich,inpublichealthterms,arefarmoredevastatingforthepopulationand whichcryoutforattention.Therootoftheproblemisthedecadesofcivilconflictthat havecausedthecollapseofhealthservicesandvastmovementsofpopulation;during thewetseasonmanyareasareinaccessibleduetoflooding.However,therearealso casesinareasofthesouthwithingovernmentcontrol,andinthenorthofthecountry whichdemandattention. Lymphaticfilariasis,endemicinEgypt,SudanandYemen,istargetedforglobal elimination,i.e.thereductionoftransmissiontolevelsbelowwhichthediseasecannot sustainitself.Protocolsofproveneffectiveness,developedbytheGlobalProgramme fortheEliminationofLymphaticFilariasishavealreadybeenimplementedinEgypt; withannualmasstreatmentinendemicareasandthepromotionofproperdisease managementbycontrollingsecondaryinfectionandwashingtheaffectedgrossly swollenlimbs.InYemen,surveillanceactivitiesbeganin1999andin2002drug treatmentwasofferedinelevenendemicareas.However,bothinYemenandinSudan, theprogrammeneedstobeexpanded.InSudan,wheremanycasesarelikelytobe inthesouth,therehavesofarbeenonlypreliminaryattemptstodevelopaneradication strategyandtoidentifyendemicareas.

AllcountriesintheRegionhavenowachievedthegoalofeliminationofleprosyasa publichealthproblematthenationallevel;thisisdefinedasanoverallprevalenceof lessthanonecaseper10000people.However,incountrieswherehigherratespersist insomedistricts,moreactionisneeded.Multidrugtreatment,responsibleforan85% globaldeclineintheprevalenceofleprosyoverthepast15years,cannowbeprovided atprimaryhealthcarecentres,orinthehome.WHOprovidesallendemiccountries withdrugsforleprosytreatmentfreeofcharge.Yetbecauseofthestigmaassociated withthedisease,peopleremainreluctanttocomeforwardfordiagnosisandtreatment. Anumberofzoonoticdiseases,whichhavethecapacitytospreadfromanimalsto humans,arealsosignificantintheRegion,suchasbrucellosisandrabies.Rabies controlstrategiesfocusonvaccinesforpeoplewhomayhavebeenbittenbyarabid animal,andcontrolofferaldogsandcatsandotherreservoirhosts.Collaboration betweenhealthandveterinaryauthoritiesisessentialforthecontrolofzoonotic diseases,butoftenlacking. Aswehaveindicatedabove,provenstrategiesexistforthetreatmentandcontrolof communicablediseasesintheRegion.Yettherearemanybarrierstotheirfull implementation,sotheycanreachallthepeoplewhoneedthem. Themainquestionforcommunicablediseasecontrolis:Whatarethechallengeswhich urgentlyneedtobeovercomeinordertostrengthenthenationalresponseto communicabledisease?

Dracunculiasis (guinea-worm disease)hasbeen thetargetofaglobal eradication programmesince theearly1980s. Seventy-fiveper cent(75%)ofthe remainingcases, worldwide,are foundinSudan, mainlyinthesouth ofthecountry. Lymphaticfilariasis, endemicinEgypt, SudanandYemen istargetedforglobal elimination.

WHOprovidesall endemiccountries withdrugsfor leprosytreatment freeofcharge. Rabiescontrol strategiesfocuson vaccinesforpeople whomayhavebeen bittenbyarabid animal,andcontrol offeraldogsand catsandother reservoirhosts. Collaboration betweenhealthand veterinary authoritiesis essentialforthe controlofzoonotic diseases,butoften lacking. 18

PART1CommunicableDiseasesintheEasternMediterraneanRegion

P ART 2 Challenges

Nationalcommitmentandleadership Strengtheninghealthsystems Ahugetask Buildingtrust Respondingtochange:thepublic-privatemix Developinganintegratedapproach: cross-cuttingactivities Whyintegrationisneeded Focusingoncross-cuttingactivities Capacitybuilding Advocacy Infectioncontrol Containmentofanti-microbialresistance Managementofinsecticideresistance Operationalresearch Surveillanceforecasting&epidemicmanagement Partnershipforhealth Expandingintersectoralcollaboration Workingwithinternationalpartnerships Communityparticipation FacingrealitiesintheRegionandtheworld Complexemergencies Aborderlessworld

NA TIONAL COMMITMENT AND LEADERSHIP

Nationalleadershipfortheessentialtaskofcommunicablediseasecontrolisstillweak insomecountriesoftheRegion.Nationalleadersarewillingtosupportprogrammes thattheyknowwillhaveawideappealbuttheytendtoignorelesspopularcauses. Globally,andwithintheEasternMediterraneanRegion,programmestovaccinateyoung childrenreceivesupportbecauseeveryonevaluesthelivesofyoungchildren.The decliningnumberofcasescanbeusedtodemonstratetheimpactoftheseprogrammes. Unfortunately,manyothercommunicablediseasesthatcanberelativelyeasilycontrolled oftenhavefewpowerfuladvocates.Diseasesofthepoor,suchastuberculosis,malaria andAIDSareonlynowbeingrecognizedastargetsforinternationalandnational attention.Diseasesofpovertycontributethegreatestburdenonsociety–onindividuals, thecommunityandthehealthservices.Mostsufferers,becausetheyarepoor,have novoiceinnationalpolicy,andareofteninvisibletopolicymakersastheyliveinremote areasorurbanslumsbeyondthereachofregularhealthservices.Nationalleadership isessentialtosupportthedevelopmentandimplementationofahealthsystemthat respondstotheseneeds.

STR ENGTHENING HEALTH SYSTEMS

Ahugetask Thedemandsonthepublichealthserviceareenormous,andultimatelysomebodyhas topayforit.Programmestoprovideforchildhoodimmunization,anddiagnosisand treatmentfordiseasessuchastuberculosis,malariaandleprosy,shouldbeoffered free,forthebenefitofindividualsufferers,butmoreimportantly,fromapublichealth pointofview,topreventotherpeoplefrombecominginfected. Healthservicesmustidentifypeoplewhosufferfromthesediseases,andpersuade themtocomeforwardfordiagnosisandtreatment.Theyneedtoexpandtoreacha rapidlygrowingpopulation,inwhich40%ofthepeopleareunder15yearsold,and aretheagegroupmostvulnerabletocommunicablediseases.Healthsystemsmust reachouttoeveryone,richandpoor,wherevertheylive,inremoteruralareasorurban slums.Tofailtodosoendangersthehealthofallcitizens.Atthesametime,patterns ofhealthprovisionarechangingrapidly,andmanyservicesonceprovidedbyministries ofhealtharenowprovidedbyparastatalorganizations,privatefor-profitprovidersand thevoluntarysector. Inallexceptthesmallest,richestcountriesoftheRegion,healthservicesaregrossly underfunded.Eventhoughstaffarepoorlypaid,70%–80%ofhealthallocationgoes onsalaries.Littleisleftoverforthemaintenanceoffacilities,thesupplyofdrugsand materials,outreachandhealthpromotion,anddiseasesurveillance.Yet,theproblem isnotonlyoneofshortageofmoney,butalsoofcommitment,trustandthecreative responsetochangingneeds.Ifthehealthsystemisweak,itcannotrespondeffectively totheneedsofthepeople.Ifpeopleperceivethatthesystemdoesnotrespondto theirneeds,theywillnotuseitsservices. Thechallengeistostrengthenthepublichealthsystemsinthediversecountriesof theRegionsothattheycanprovidetheessentialservicesneededbytheircitizens.

Nationalleadersare willingtosupport programmesthat theyknowwillhave awideappealbut theytendtoignore lesspopularcauses. Healthsystems mustreachoutto everyone,richand poor,whereverthey live,inremoterural areasorurban slums.

Ifpeopleperceive thatthesystem doesnotrespondto theirneeds,theywill notuseitsservices. Thechallengeisto strengthenthe publichealth systemsinthe diversecountriesof theRegionsothat theycanprovidethe essentialservices neededbytheir citizens.

CHALLENGES

PART2Challenges 22

Buildingtrust Thechallengeistobuildtrustinthehealthsystem,sothatproviderscanperform effectivelyandgivethepublicaccesstogoodservicesthatsatisfytheirneedsfor healthandfordignity. Thekeyconceptsherearetransparency,integrity,opennessandresponsibilityinthe performanceofallthetasksrequiredofthesystem.Toachievetransparency,planners needtoidentifypriorities,settargetsandestablishstrategiesforreachingthem.Ifthis isdone,andtheresponsibilitiesoftheprovidersareclearlyidentified,theyshouldbe abletorespondeffectivelytotherealneedsofthepublic.Ifactivitiesaresuccessful, theycanbeusedtostrengthenthecommitmentofinternationalfundingagencies,and nationalandregionalauthoritiesforthecriticaltaskofcommunicablediseasecontrol. Animportantaspectoftransparencyistheprovisionofaccurateinformationandits useindecision-making.Therightinformationshouldbeseentobeintherightplace, intherighthandsandattherighttime.Informationprovidedbyhealthauthorities shouldbetrustedforitsaccuracyandtimeliness,andsharedamongthosewhoneed itforplanningandimplementingdiseasecontrolprogrammes. Transparencymeansthatsurveillancesystemsareconsistentandaccurate,andthat staffaretrainedtorecorddataandunderstandwhytheyaredoingit.Transparency increasesthemotivationofhealthproviders,whoneedtoknowwhattodo,whyto doit,andhavetheknowledgeandmaterialstorespondtotheneedsofthecommunity ofwhichtheyarepart. Transparencyandopennessinthenationalhealthsystemshouldprovideincreased motivationandopportunityforcommunitymemberstobecomemoreinvolvedinhealth relatedactivities.

Informationprovided byhealthauthorities shouldbetrustedfor itsaccuracyand timeliness,and sharedamongthose whoneeditfor planningand implementing diseasecontrol programmes.

HIV/AIDSisonlyoneofthediseasesthatpatientsassociatewithstigmaandthefear ofrejectionbytheirfamiliesandcommunities.Peoplesufferingfromtuberculosisand leprosyarealsoreluctanttoadmitthattheymayhavethediseaseandseekdiagnosis andtreatment.Cutaneousleishmaniasis,whichcausespermanentscarring,especially ontheface,oftenresultsinthesocialexclusionofinfectedwomen.Inallthesediseases, opennessandtransparencycanencouragepeoplewhothinktheyhavethedisease toreportfortreatmentatanearlystage,beforeitdoespermanentdamage.Health ministrieshaveanimportantroletoplayinovercomingstigmabyprovidingeducation forthepublicabouthowthediseaseisspread(ormoreimportantly,notspread)and whatcanbedonetopreventtransmission.Atthesametime,itcanpromotea sympatheticatmosphereinhealthcentresthatencouragespeopletoseektreatment.

BUILDINGTRUST:HIV/AIDS LackoftransparencyisattheheartofthedifficultiesintacklingHIV/AIDSintheRegion.Thereisawidediscrepancybetween thenumberofcasesreported,12158AIDSand36031HIVbytheendyear2002,andtheestimatednumberofpeopleliving withHIV/AIDS,around750000.Onlyasmallpercentageofthecasesdiagnosedareactuallyreported.Governmentagencies maynotbeinterestedincollectingandpublishingdataonHIV/AIDSastheyfearitwillreflectbadlyontheirnationalreputation anddetertourists.Thereislittlemotivationforproviderstoreportcasesasthereislittlesupportinthehealthsystemforpeople whoarelivingwithAIDS. MembersofthepublicintheRegionarereluctanttosubmittoatestforHIVbecauseofthestigmaattachedtothedisease. Stigmaisrelatedtothegeneralunwillingnesstoidentifyandopenlydiscussissuesrelatingtosexuality.Thereisawidespread beliefamonghealthprovidersandthepublicthatsexoutsidemarriageisrare,andthustherearefew,ifanypeopleintheir owncommunitieswhohaveHIV/AIDS.

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Themainconcernofprivateproviders,whethertheyarefor-profitorrunby nongovernmentalorganizations,istoprovidediagnosisandtreatmentforindividual patients.Theydonotconsiderthattheyshouldbeconcernedwithpreventionand surveillance,althoughthiswouldbenefitthewholecommunity.However,because theytreatmanypatients,itisessentialforthemaintenanceofdiseasecontrolthat theybeinvolvedinthesecentralactivities.Howthiscanbedoneinwaysthatdonot appeartobecuttingintotheabilityofprivateproviderstomakeaprofitisatpresent notclear.Asyet,therearefew,ifany,provenstrategiesforsuchcollaborationand manyhealthplannersperceivethattheinterestsofthepublicandtheprivatesector arefarapart. Thechallengehereistoidentifyapublic–privatemixthatcomplementsandstrengthens overallhealthperformance. WhenDOTS,themultidrugstrategyfortreatmentoftuberculosis,wasfirstpromoted intheRegion,in1996,itwasorganizedthroughthegovernmenthealthsector,asfree treatmentwasidentifiedasessentialtoachievehighcureratesandcontroldisease transmissioninthecommunity.However,privateprovidersarenowtreatingagrowing percentageoftuberculosispatients.Therefore,theRegionalOfficeispromoting partnershipstoinvolvetheprivatesectorinDOTS.Thisfacesproblemsbecausemuch oftheprivatesectorremainsunregulated,andprivateprovidershaveonlyalimited knowledgeoftuberculosis.

Thechallengehere istoidentifya public–privatemix thatcomplements andstrengthens overallhealth performance.

Respondingtochange:thepublic–privatemix Nationallyfundedhealthservicesinmanycountriesarechangingrapidlyandfewstill havethesoleresponsibilityforhealthsectoractivities.Othergovernmentauthorities havelongbeenresponsibleforprovidinghealthcareforschoolchildren,forthemilitary andforprisoners.Moreover,today,ministriesofhealtharedevolvingmanyoftheir responsibilitiestosemi-governmentalorganizationssuchashealthinsuranceschemes forgovernmentemployees,forschoolchildrenandforthoseonpublicassistance. Healthministriesarealsoundergoingreforms,suchasdecentralization,thattheyhope willimprovethosekeyservicesthatremainundertheirdirectcontrol.Atthesame time,governmentshaveencouragedtheexpansionoftheprivatesector,boththefor- profitandnon-governmentalproviders.Privatehealthcarehasalsogrowninresponse topatients’beliefthatpublicsectorcaredoesnotmeettheirneeds. Egyptprovidesagoodexampleofthemanydifferentsectorsthatarenowinvolved inhealthcare.Astudycarriedoutinthe1990sfoundthattheMinistryofFinance providedonlyathirdofthetotalfunding,ofwhichlessthan60%wasspentonfacilities administeredbytheMinistryofHealth.Overone-thirdofallhealthexpenditurewas spentbypatientsatpharmacies. Figure5:Nationalhealthaccount,Egypt1997 Otherprivate 5%Non-governmental organizations1%Ministryofhealth andpopulation 19% Otherpublic 3% Universities 10% Healthinsurance organizations 8%Providers 18%

Pharmacies 36%

PART2Challenges 26

Themainconcernof privateproviders, whethertheyare for-profitorrunby nongovernmental organizations,isto providediagnosis andtreatmentfor individualpatients. Theydonot considerthatthey shouldbe concernedwith preventionand surveillance, althoughthiswould benefitthewhole community.

Anotherpublic-privateinitiativeisbeingexplored,inthisinstancetocontrolmalaria byprovidinginsecticide-treatedbednets.Pilotprojects,workingthroughthepublic sector,haveshownthatthesehaveresultedinadeclineinmalariainfection,especially amongyoungchildren,whohavenotyetacquiredpartialimmunitytothedisease.As theseprojectsareextended,theinvolvementoftheprivatesectorinprovidingbednets forthosewhocanaffordthemcantakeadvantageoftheirexperienceincreatinga demand,throughsocialmarketing.InSudan,bednetprovisionrequirestheidentification oflocalfirmswillingtomanufacturebednetstospecifications,andavoidanceofa monopolysituationinwhichmanufacturerscansettheirownprices. Eveniftheprivatesectorcanprovidebednets,thepublichealthservicewillstillneed tohelptocreateanenablingenvironment,bydevelopingguidelinesandensuringthat taxesandtariffsonbednetsareremoved.Itwillalsoneedtoensurethatthosewho cannotaffordtopayarealsoprovidedwithbednets.Inverypoorcountriesandthose incomplexemergenciespublicdistributionandpromotionofbednetsmaywellbethe strategyrequired.

DOTSINPAKISTAN InPakistan,whichhasadisproportionatelylargeshareoftuberculosiscasesinthe Region,theprivatesectornowprovides80%ofthecountry’shealthservices.AWHO- supportedresearchprojectfoundthatfewprivateprovidersknewthecorrecttreatment regimefortuberculosisorreferredcasestothenationalprogramme.Proposalsfora public–privatepartnershiparecomplicatedbytheplan,introducedinAugust2001,to decentralizethepublicsector,movingresponsibilityforhealthcaretothedistrictlevel. IfdistrictauthoritiesdonotconsiderDOTSahighpriority,theprogrammewillsuffer. Also,weakmanagementandsupervisionmayhinderactivitiesattheprovincialand districtlevels,especiallyplansfornewpartnerships. DOTSINEGYPT InEgypt,itisestimatedthat30%oftuberculosispatientsaretreatedoutsidethepublic sectorandhalfoftherifampcinsuppliedbydrugcompaniesissoldthroughprivate pharmacies.TheNationalTuberculosisProgrammehasestablishedapilotprojectin urbanCairo,inwhichprivateprovidersaregiveninformationandnotificationforms;the firstresultsindicateanincreaseincasenotificationinthepilotareas.InEgypt,itisalso importantfortheprogrammetoworkwithnongovernmentalorganizations,whichhave asignificantroleinidentifyingtuberculosiscasesamongthepoorandprovidingthem withrelativelyhighquality,low-costandaccessibleoutpatientservices.

PUBLIC–PRIVATEMIX Whydoweneedit? •Toreachprivateproviders •Toincludeprivatepatientsinthesurveillancesystem •Toensurepropercareintheprivatesector Howdoweachieveit? •Identifystrategiesthatdonotthreatentheinterestsofprivateproviders •Providetrainingandotherservicesforprivateproviders

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AWHO-supported researchproject foundthatfew privateprovidersin Pakistanknewthe correcttreatment regimefor tuberculosisor referredcasestothe national programme.

Inverypoor countriesandthose incomplex emergenciespublic distributionand promotionof bednetsmaywell bethestrategy required.

DE V ELOPING AN INTE GRA TED APPR OACH: CR OSS-CUTTING ACTIVITIES

Whyintegrationisneeded Thefocusonprimaryhealthcare,whichbeganinthe1970s,emphasizedcommunity- basedpreventionandarangeoflow-techapproachestothediseasesmostcommonly foundinpoorcountries.Economiccrisis,includingdebtrepayment,hinderedthe developmentofthispolicy.Attemptstogetpoorpeopletopayfortheirownhealth carefounderedbecausetheysimplycouldnotaffordit.Theyoftenwentwithoutcare anddiedyoung:healthservicesinthepoorestcountriescollapsed. Verticalprogrammesweredevelopedoutsidetheregularhealthstructure,whichwas consideredtooweaktosupportthem,inordertomaintainessentialservicessuchas immunizationforchildhooddiseases.Gradually,mostinternationalhealthagencies cametobeorganizedaroundsuchprogrammes.Onthenationallevel,eachofthese diseasespecificprogrammeshasitsownspecificbudget,targetsandactivities,and isorganizedseparatelyatthenationalanddistrictlevel.However,atthelocallevel theseseparateprogrammesareusuallyadministeredthroughthenetworkoffacilities andstaffthatcomprisetheprimaryhealthcaresystem.Aspresentlyconstituted,the administrationofseparateprogrammesleadstoaconsiderableamountofoverlapand duplicationofeffort.

Theseverticalprogrammesappealtophysicianstrainedintheareaofcommunicable diseaseswhousuallyconsiderthemselvesspecialistsinparticulardiseases,orgroups ofdiseases,suchasrespiratoryinfectionsorparasiticdiseases.Intheircapacityas policy-makersatthenationallevel,asmanagersandasclinicianstheythinkprimarily intermsofthecontrolofspecificdiseases,ratherthanlookingatthebroaderhealth picture.Today,theyoftenlackaclearvisionofhowhealthstaffdealingdirectlywith thepubliccanprovidecareforthemostcommondiseases,and,atthesametime, performtheotheressentialservicesforthepreservationofhealth. Thechallengeistodevelopaholisticviewofhealththatlooksatallaspectsofthe situation,ratherthanthinkingintermsofcontrollingeachseparatedisease.

Theadministration ofseparate programmesleads toaconsiderable amountofoverlap andduplicationof effort.

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Thechallengeisto developaholistic viewofhealththat looksatallaspects ofthesituation, ratherthanthinking intermsof controllingeach separatedisease.

Focusingoncross-cuttingactivities Atthesametimeasdevelopingaholisticview,healthservicesshoulddeliverservices inthemosthumaneandcost-effectiveway.Asfaraspossible,formerlyseparate diseaseprogrammesshouldbeintegratedatvariouslevelsandbetweensectors.This approachisvalidevenifthediseasesaredissimilar,ascertaincross-cuttingactivities areusedinthecontrolofalldiseases.ThenewstructurefortheEMRODivisionof CommunicableDiseasesidentifiescross-cuttingactivitiesthatarecommonconcerns forallthosewhoplanandimplementcommunicablediseasecontrolprogrammesand workinthepublichealthsystem.Focusingoncross-cuttingactivitiescanhelptoforge cooperation,ratherthancompetitionbetweenthevariousdiseasesectors. Thechallengeistostrengthenandmakefulluseofthesecross-cuttingactivitiesto combineprogrammeactivitiesandavoidduplicationandwasteofscarceresources. InFebruary2002ameetingatEMROreviewedtheregionalstrategyonintegrated communicablediseasecontrol.Representativesofnationalprogrammesofcommunicable diseasesurveillanceandcontrolinPakistan,SudanandYemendiscussedthedifferent strategiesforcross-cuttingactivities,andconcludedthatintegrationwouldleadtoa betteroutcomeforhealthplansandanoptimumuseofresources. Capacity-building Capacity-buildingisthefirstofthesecross-cuttingactivities.Itinvolvesupgrading facilities.Laboratoriesfordiagnosticstudiesareespeciallyimportantforthepublic healthservices,astheyarenotsuppliedintheprivatesector,whichregardsthemas unprofitable.Allfacilitiesneedup-to-dateequipmentandtoensurearegularflowof supplies. Healthsystemsdependonclinicalstaffresponsiblefortheday-to-daydeliveryof services,aswellastrainedpolicy-makersandmanagerswhocanidentifyandsolve problems,makedecisionsandcarrythemout.

Thechallengeisto strengthenand makefulluseof thesecross-cutting activitiestocombine programmeactivities andavoid duplicationand wasteofscarce resources AnewstructureforDCD:Cross-cuttingactivitiestopromoteeffectivecommunicablediseasecontrol

CROSS-CUTTINGACTIVITIES DIRECTOR COORDINATORCOORDINATOR

DISEASE-SPECIFIC ACTIVITIES AIDS&SEXUALLY TRANSMITTED DISEASES PARASITIC&ZOONOTIC DISEASESVACCINE-PREVENTABLE DISEASES&IMMUNIZATIONEMERGING&EPIDEMIC DISEASES

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CAPACITY-BUILDING REASERCH ADVOCACY INFECTIONCONTROL&CONTAINMENT OFANTIMICROBIALRESISTANCE

SURVEILLANCE,FORECASTING ANDEPIDEMICMANAGEMENT ROLLBACK MALARIASTOPTB

InFebruary2002a meetingatEMRO reviewedthe regionalstrategyon integrated communicable diseasecontroland itwasconcluded thatintegration wouldleadtoa betteroutcomefor healthplansandan optimumuseof resources.

Forexample,importantdecisionsaboutchargestopatientsrequireacomprehensive, holisticassessmentoftheburdenofdiseaseonindividualsandtheirabilitytopayfor care,aswellasoftheriskofcontinuedtransmissioninthelocality.Inthecaseofmalaria, drugsfortreatmentandinsecticidesformosquitocontrol,neededbythepoorestpeople inthepoorestcountries,areexpensive.Acountrythathopestosolvetheproblemby chargingpatientsmaysimplymaketheproblemworsebydrivingthemawayandtaking theirinfectivebodieswiththem.Poorpatients,whotreatthemselvesanddelaycoming tothehealthcentres,risktheirownlifeandhealth,andburdenhospitalserviceswhen theyarefinallyadmitted. Advocacy Advocacyprogrammesforcommunicablediseasecontrolinitiativesneedtoensurea consistenttargetedapproach.Theyneedtoenlistthesupportofnationalgovernments, healthministries,andthegeneralpopulation.Advocacycanworkinavarietyofways; atthehighestlevelthroughgovernmentsandministries,andthroughmassmediaand community-basedactivitiestoreachthegeneralpublic.Theyneedtofocusonthe CHARGINGFORMALARIATREATMENTINSUDAN? InSudan’sWhiteNileState,whichhasrelativelygoodhealthcarefacilities,theproportion ofsevereandcomplicatedfalciparummalariabeingtreatedinhospitalsisincreasing. Thisislikelytobehappeningbecausepatientscannotaffordtopayformalariadiagnosis andmedication,andthusdelayseekingtreatmentuntiltheyareseriouslyill.Insuch settings,costsharingstrategiesareundercontinualreview.

benefitsforthepublicatlarge,ratherthanjustforindividuals.Clinicians,andthemany national-levelhealthofficialswhoweretrainedasclinicians,needtobeconvincedof thevalueofthis,astheirtrainingorientsthemtowardsthecareofindividualsrather thanthecommunity-wideapproach. Anotherimportantobjectiveofadvocacyprogrammesistochangeattitudesamong thegeneralpublic.Thisisespeciallyimportantforstigmatizingdiseasesandforemerging diseasesthatarenew,unfamiliarandhenceparticularlyfrightening. Activitiesneedtoextendbeyondgloballyobservednationaldays,suchasthosefor HIV/AIDS,tuberculosisandmalaria,andkeepupthemomentum.Atthelocallevel, follow-upactivitiesneedtobesupportedbylocalhealthcentres,schoolsandcommunity organizations,wherelocalpeoplecaninitiatefurtherdialogue.Successincommunicable diseasecontrolforonediseaseatthenationallevelcanbeusedinadvocacyatthe locallevelforthecontrolofotherdiseases.Localleveladvocacywillalertlocalpeople todiseaserisksofwhichtheywerepreviouslyunaware. ADVOCACY Whydoweneedit? •Tobuildsupportforprogrammesatinternational,national,regionalandlocallevels Howcanweachieveit? •Outreachatalllevels:international,national,districtandlocal •Usingallmedia—television,radio,newspapers—aswellasface-to-faceactivities atthelocallevel

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Infectioncontrol Infectioncontrol,includinginjectionsafety,isamajoremergingconcernintheEastern MediterraneanRegion.Ithasbeensuggestedthatupto70%ofnewcasesofhepatitis B,80%ofnewcasesofhepatitisCand6%ofnewcasesofHIVinfectionintheRegion aretransmittedbyunsafeinjections.Thesemaybeadministeredathealthcentresor byuntrainedinjectionprovidersinthecommunity. Injectionsafetyisespeciallyimportantasallantigensusedforchildhoodimmunizations, exceptforpolio,areinjected.InJuly2002WHOconductedareviewofinjection proceduresintheRegion.Thisstudysuggestedahighrisktopatientsfromnon-sterile injections;only74%ofinjectionswereadministeredsafely.Aweek’ssupplyofauto- disableinjectionequipmentwasavailableinover80%ofhealthfacilitiesvisited,but shortagesdidoccur,andreuseofinjectionequipmentwasnotuncommon. Risksforproviderswerealsoidentified;halfofhealthcareworkersadmittedtohaving hadneedle-stickinjuries.AlthoughWHO-approvedsafetyboxesforsharps(discarded needles)havebeenintroducedinmostcountriesoftheRegion,sharpswerefoundin unprotected,opencontainersin71%ofhealthfacilities. Forallcommunitymembers,thecarelessdisposalofusedsharpsposesaseriousrisk. Sharpswasteisrarelydisposedofsafely;itiseitherdumpedintheopen,orburned. Sharpswerefoundonthegroundaroundalmosthalfofthehealthfacilitiessurveyed.

ManycountriesintheRegionneedsupportandencouragementtodevelopinfection controlstrategiestoprotectthebloodsupplyandensureinjectionsafety.TheEastern MediterraneanRegionisthefirstWHOregiontodeveloparegionalstrategyfor immunizationsafety,toencourageMemberStatestodeveloptheirownprogrammes. During2002,Egyptdevelopednationalguidelinesforinfectioncontrolinheathcare settings.InSudan,theRegionalOfficereviewedimmunizationandotherinfection controlpracticesandassistedindevelopinganationalprogramme. INFECTIONCONTROL Whydoweneedit? •Topreventthetransmissionofcommunicablediseasestopatientsthroughcontaminated bloodorbodyfluids,inthehealthcaresetting •Unsafeinjectionsareariskforproviders,usersandcommunitymembers Howdoweachieveit? •Rigorousmonitoringofactivitiesinhealthcentres •Stafftrainingandmotivation •Provisionofequipmentandmaterialssuchassyringes,needlesandgloves •Monitoringthebloodsupply •Educatingthepublic

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TheEastern Mediterranean Regionisthefirst WHOregionto developaregional strategyfor immunizationsafety, toencourage MemberStatesto developtheirown programmes.

Ithasbeen suggestedthatup to70%ofnew casesofhepatitisB, 80%ofnewcases ofhepatitisCand 6%ofnewcasesof HIVinfectioninthe Regionare transmittedby unsafeinjections.

Containmentofanti-microbialresistance Thedevelopmentofresistanceindiseasepathogenstocommonlyuseddrugsisthe resultofinappropriatetreatmentbyproviders.Italsooccurswhenpatientsfailto completeacourseoftreatmentundertheguidanceofatrainedhealthprovider,or treatthemselveswithdrugspurchasedontheopenmarket.Multidrugtreatmentsfor tuberculosis,leprosyandmalaria,ifproperlyadministered,canlargelyavoidthis problem. ThehighrateofdrugresistanceintheIslamicRepublicofIranamongAfghanrefugees withtuberculosisillustratesthecomplexityofthischallenge.Therefugeeshavearate ofresistancethreetimesthatofIran’sresidentpopulation.Manyrefugeescameto Iranafterashortcourseoftreatmentorself-treatmentinAfghanistan;othersdiscontinue treatmentwhentheyreturntotheirhomecountry.Theemergenceofpathogenic immunityimperilsthewholeexistingsystemofmultidrugtreatment. CONTROLOFMICROBIALRESISTANCE Whydoweneedit? •Topreventthedevelopmentofresistanceindiseasepathogenswhichdestroys theabilityofexistingdrugstotreatcommunicablediseases Howcanweachieveit? •Rigorousenforcementandmonitoringofmultidrugtreatment •Developmentofnewdrugs •Educationforthepubliconsafeuseofdrugs

CONTROLOFINSECTICIDERESISTANCE Whydoweneedit? •Toensurethecontinuedeffectivenessofexistinginsecticidesagainstinsectvectorsofcommunicablediseases Howcanweachieveit? •Rigorousmonitoring •Useofmorethanoneinsecticide •Identifyingalternativewaystocontrolinsectvectors,suchasbiologicalcontrol Managementofinsecticideresistance Insecticideresistanceoccurswhenasingleinsecticideisusedagainstdiseasevectors, suchasmosquitoes;hardyspecimensreproducethemselves,andnewgenerations ofinsectsdevelopthatarealmostentirelyimmunetotheinsecticide.Themostnoted exampleoccurredwithDDT,usedverywidelyinthe1960sagainstmalaria.Today, resistancehasbeenreportedinmanycountriesoftheRegion,mostlydueto organophosphatesandorganochlorinesusedinagriculture.Itisnotyetknownif mosquitoesintheRegionareresistanttopyrethroids,arelativelyeffectiveand environmentallysafegroupofinsecticides. Becauseoftheriskofmalariainremainingendemiccountries,andthepossibilityof resurgenceinotherareas,thereisanurgentneedtoidentifystrategiestopreventthe developmentofinsecticideresistance,suchasusinginsecticidesinrotation.Itisalso importanttodevelopstrategiestodetect,monitor,mapandmanageinsecticide resistance. Thepossibilityofthedevelopmentofentirelynewinsecticidesislimited,asthereis littlecommercialincentiveforcompaniesintheindustrializedcountriestodevelopnew productsformalaria.Thedevelopmentcostsarehighandthedemandislargelyfrom poorcountriesthatcannotaffordtobuyexpensivenewproducts.

PART2Challenges 38

Multidrug treatmentsfor tuberculosis,leprosy andmalaria,if properly administered,can largelyavoidthis problem.

Thereisanurgent needtoidentify strategiestoprevent thedevelopmentof insecticide resistance,suchas usinginsecticidesin rotation.

Operationalresearch TheSmallGrantsSchemeforOperationalResearchinTropicalandCommunicable DiseaseshasbeensupportedbyWHORegionalOfficefortheEasternMediterranean since1992.TheprogrammewasoriginallyfundedbyTDR(UNDP/WORLDBANK/WHO SpecialProgrammeforResearchandTraininginTropicalDiseases)andcoveredthree oftheTDRprioritydiseases,malaria,leishmaniasisandfilariasis.In2002itexpanded tocoverotherdiseases,includingtuberculosis,meningitis,viralhaemorrhagicfevers andvaccine-preventablediseases.Forthefirsttime,in2002,therewereapplications forresearchonHIV/AIDS. ResearchcapabilityinmanypartsoftheRegionisweak.Theregionalofficeisina positiontobeabletoidentifymajorappliedresearchgaps,andeachyearinvites researchproposalsinthoseareas.TheSmallGrantsSchemeforOperationalResearch inTropicalandCommunicableDiseasessupportsresearchersatallstages—fromthe preparationoftheapplication,throughtheresearchprocess,tothedisseminationof results.Thenextstageistohelpsuccessfulresearchteamstoapplyforlargergrants, basedontheexperiencetheyhavealreadygained. RESEARCHONLEISHMANIASIS Pastresearchprojectsonvisceralleishmaniasis,aseriousdiseasewithahigh mortalityrateifleftuntreated,haveincluded:GIS(geographicinformationsystems) mappingofriskinsouthernSudan,andthedevelopmentofareliable,rapidand sensitivediagnostictestforthedisease.Anotherprojectstudiedtheepidemiology ofthelessseriouscutaneousleishmaniasisinthePalestiniandistrictofJericho. Thisstudyidentifiedtheseasonalityoftransmission,highestfromOctoberto January,andfoundthediseasemoreprevalentamongyoungPalestinianscamping ontheoutskirtsofthetownandamongBedouinwomenandfarmers’wives.The nextstepistoapplythisknowledgetocontrolinthelocalsetting.

RESEARCH Whydoweneedit? •Tofillknowledgegaps •Toidentifypossibleinnovativecontrolstrategies Howdoweachieveit? •Supportandstrengthenlocally-basedoperationalresearchdirectedtowards specificproblems

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Surveillanceforecasting&epidemicmanagement Asurveillancesystemmustprovideeffectiveandtimelyinformationfordetectingand controllingdiseaseoutbreaks.Italsoassistsinplanningandimplementinghealth policiesatinternational,nationalandlocallevels.Suchactivitiescanonlybeperformed throughapublichealthsystem;ifthissystemisweak,surveillancewillbeweak. Apublichealthsystemmusthavethecapacitytotrackepidemic-pronediseasesand respondrapidlywhentheydooccur.Thisrequiresaneffectivesurveillancesystem,a supplyofessentialdrugsandinsecticides,andtrainedstaffreadytorespondandable toreachtheaffectedareas.Yet,intheRegion,theareasmostpronetoepidemic outbreaksarethosethatareleastabletomaintaineffectivemonitoringandresponse systems. Inmostnationalhealthservices,theexistenceofanumberofverticallyorganized diseaseprogrammesmeansthatdifferentsurveillancesystemsexistforeachdisease orgroupofdiseases.Thisduplicationiswastefuloftrainedpersonnel,timeandmoney. HealthinformationpublishedbyWHOanditsregionalofficesdependsondatasubmitted byMemberStates.Theseinturndependonreliabilityofregionalandlocalrecording systemsoperatingthroughnationalhealthministries. Inaccuratedatamakesproperplanningdifficultandhinderseffectivediseasecontrol. Inaccuratefiguresmaybetheresultofinconsistentcasedefinitionsforthevarious diseases,poorlydesignedreportingsystems,andafailureofstafftoadheretoregular reportingschedules.Under-reportingofdiseasemorbidityandmortalityandepidemics isespeciallycommoninremoteareasandinareaswithcomplexemergencies.Outbreaks ofdiseaseamongpoorpeople,migrantsandnomadsarealsooftenunder-reported. Yet,thesearetheareasandpeopleinthegreatestneed. AsmanycountriesintheEasternMediterraneanRegiondonotyethavecontingency plansforepidemic-pronediarrhoealdiseases,aregionalstrategytoensureepidemic preparednesswasdevelopedandendorsedbytheRegionalCommitteefortheEastern Mediterraneanin2002.Thetargetisforallcountriestohavethecapacityforearly detectionandrapidandeffectiveresponsetooutbreaksofdiarrhoealdiseaseby2005. SURVEILLANCE Whydoweneedit? •Toprovideinformationaboutcommunicablediseases&their distribution,&earlywarningofepidemics •Tofacilitaterapidandappropriateresponsestodiseasecrises Howcanweachieveit? •Upgradingandcoordinatingrecordingsystems •Trainingstaff •Monitoring •Feedback

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Theareasmost pronetoepidemic outbreaksarethose thatareleastable tomaintaineffective monitoringand responsesystems. Inaccuratedata makesproper planningdifficultand hinderseffective diseasecontrol.

Aregionalstrategy toensureepidemic preparednesswas developedand endorsedbythe RegionalCommittee fortheEastern Mediterraneanin 2002.

P A R TNERSHIPS FOR HEALTH

Expandingintersectoralcollaboration AchievinggoodhealthforthepopulationoftheRegionisatasknotonlyforthehealth sector.Healthministriesneedtocollaboratewiththeministriesresponsibleforwater andsanitation,housing,agriculture,irrigationandtheenvironment,tohelptoestablish andimplementstrategiesthatwillimprovethehealthofallthepeopleoftheRegion. Ashealthandpovertyareinextricablyintertwined,healthissuesneedtobeincorporated intoprogrammesofpovertyalleviation,forexampleliteracyprogrammesandemployment creationactivities,suchassmallloansforwomentoestablishcraft,tradingoranimal raisingenterprises.Thesecannotbecarriedoutiftheskills,knowledgeandneedsof thepoorareneglected. Thechallengeistofostermoreeffectivecooperationbetweenthehealthsectorand otherrelevantsectors,atthenationalandlocallevels. ManygovernmentbureaucraciesintheRegionremainhighlycentralized,witheach ministryoperatingindependentlyandmaintainingachainofcommanddowntothe locallevel.Today,thetrendinhealthandlocalgovernmentreformistowards decentralization,withdecisionsbeingmadeatthedistrictandlocallevel,whereitis hopedthattheycanreflectlocalneeds.Atthelocallevelthereisgreatscopefor cooperationamongthedifferentsectorsofthebureaucracy.Foritisatthislevelthat communicablediseasesaretransmitted,andareusuallytreated,andwheretheycan mosteffectivelybeprevented.

Intersectoralcollaborationatalllevelsneedstobeseenasmutuallybeneficial,rather thanasanencroachmentonthedomainsoflongestablishedbureaucracies.Disease controlrequirescollaborationbetweenhealthspecialistsandarangeofothergovernmental authorities,suchasthoseresponsibleforcommunicationsandeducation,inorderto reachthepublic.Collaborationwitheducationauthoritiescanreachprimaryschool children;theyarereceptivetargetsforhealthmessages,andcanalsoinfluencetheir siblings,andeventheirparents,abouthealthrisksinthecommunity.Youngchildrencan alsobereachedthroughschoolsfortreatmentforparasiticinfections,astheyhave higherratesofinfestationthanotherpopulationgroups. Collaborationbetweenthehealthandveterinaryservicesisneededforthecontrolof zoonoticdiseases,whicharespreadfromanimalstohumans.Humanbrucellosiscannot betackledwithoutcontrollingthelivestockdisease,ataskfortheveterinarydepartment. Inthecaseofcutaneousleishmaniasis,collaborationwiththepestcontrolunitsinthe ministriesofagricultureisneededtofacilitateearlydetectionandpreventionthrough surveillanceprogrammestomonitorrodentpopulationexplosionsthatarelikelyto precedeoutbreaksinhumans.Collaborationachievedinanemergencysituation,asin therecentoutbreakofleishmaniasisinAfghanistan,needstobeestablishedonaregular basis.

Intersectoral collaborationatall levelsneedstobe seenasmutually beneficial,rather thanasan encroachmenton thedomainsoflong established bureaucracies. Diseasecontrol requires collaboration betweenhealth specialistsanda rangeofother governmental authorities.

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Thechallengeisto fostermore effective cooperation betweenthehealth sectorandother relevantsectors,at thenationaland locallevels. Collaboration betweenthehealth andveterinary servicesisneeded forthecontrolof zoonoticdiseases.

Collaborationwithlocalauthoritiesresponsibleforwater,sanitationandirrigationis essentialbecausemanycommunicablediseasesintheRegionarewater-related.The absenceofsafewater,sanitationandadequatedrainagecreatesconditionsforthe transmissionofdiarrhoealdiseases,schistosomiasisanddracunculiasis.Mosquitoes thatbreedinopenwaterarevectorsformalaria,denguefever,yellowfeverand lymphaticfilariasis.Workingtogether,healthministriesandministriesresponsiblefor providingdomesticwater,sanitationandirrigationcanidentifyprioritiesandeffective strategiesforprovidingsafewaterandsanitation,upgradingthequalityofwaterin riversandirrigationcanals,andlimitingtheamountofstagnantwaterthatmight providebreedingsitesforinsectvectors. Schistosomiasisisadiseasethatistransmittedbyhumanactivitiesassociatedinone wayoranotherwithwater.Thosewhoareinfected,throughcontactwithcanalwater duringfarming,recreationordomesticactivities,canbesuccessfullytreatedwith praziquantel.However,theyarelikelytobereinfectediftheydonotchangetheir behaviour,andifnoimprovementsinwaterandsanitationaremadetopreventthe contaminationofcanals. INTERSECTORALCOLLABORATION Whydoweneedit? •Becausethehealthofthepopulationisadverselyaffectedbypoverty,lackofsafe waterandsanitation,poorhousing,illiteracy,unsafeandunhygienicenvironments Howdoweachieveit? •Collaborationbasedonsharedconcerns,especiallyatthelocallevel SCHISTOSOMIASISCONTROLINEGYPT InEgypt,theNationalSchistosomiasisControlProgramme,organizedthroughtheMinistry ofHealthandPopulation,providesfreediagnosisandtreatmentwithpraziquantel.Other aspectsoftheintegratedcontrolprogrammearevectorcontrol,andhealthpromotion toencouragepeopletogofortreatmentandtoavoidcontactwithcanalwater. Collaborationwiththerelevantauthoritiestoprovidesafewaterandsanitationisalso partoftheintegratedprogrammebut,inpractice,itreceiveslessattention.Recently, thenationalprogrammehashadtoprovidediagnosisandtreatmentthroughtheHealth InsuranceOrganization,aparastatalorganizationindependentoftheMinistryofHealth andPopulationwhichprovidesservicesfor16millionschoolchildren,aswellasall governmentemployees.

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Workingtogether, healthministriesand ministries responsiblefor providingdomestic water,sanitation andirrigationcan identifyprioritiesand effectivestrategies forprovidingsafe waterand sanitation.

Workingwithinternationalpartnerships Today,internationalprogrammestotacklecommunicablediseasesintheRegioninvolve morepartnersthaneverbefore.Thesenewpartnershipshavethepotentialtosupply muchneededfundingfordiseasecontrol,tosupportthedevelopmentofnewtools suchasdrugsandvaccines,andtobuildupthecapacityofhealthsystemstodeliver existingandnewtools.However,theconceptofpartnershipneedstobeclearly understood,foritrequiresmutualtrustandopennessinordertoplanandcarryout jointprogrammes.Thesenewpartnershipsfaceproblemssimilartothoseofthevarious differentgovernmentsectors;eachpartnerhasitsownagendaanditsownwayof thinkingaboutitsownparticularconcerns. Partnersincreasinglyrecognizethecomplexityofthetaskthatliesahead.Itisgenerally possibletotakeacomprehensiveviewofthesehealthproblemsattheinternational level,wheremostpartnershipsareinitiated.Butitismoredifficulttotranslatethese idealsintoactionatthenationallevel,andultimatelytocontributetothedeliveryof servicesatthelocallevel. EPI(ExpandedProgrammeonImmunization),oneofthelongestestablishedinternational healthprogrammes,hasfailedtoreachglobaltargetsinmanycountriesoftheRegion, andelsewhere.OneofthechallengesishowtomakethebestuseoftheGlobal AllianceforVaccinesandImmunization(GAVI),toimprovethesituation.Wealsoneed todeterminehowbesttheGlobalFundtoFightAIDS,TuberculosisandMalaria,launched inJanuary2002,cancoordinateeffortsamongitsmanypartnerstocontrolthethree mostseriousdiseasesintheRegion. AsmanyofthesepartnershipsarearrangedwithinUNagencies,theycanberegulated bythepoliciesandproceduresestablishedbytheUNagencyconcerned.Butinthe caseofnewpartners,especiallyprivatefor-profitpharmaceuticalandconsulting companies,innovativeapproachesareneededinreachingandsustainingagreements. Privatefor-profitcompanieshavebeenincludedintheGlobalFund,GAVIandother internationalpartnerships,becausetheyhavethecapabilitytosustainscientificresearch andtoprovideurgentlyneededdrugsandvaccines.However,itisimportanttoremember thatthesecompaniesarerunwithamarket-drivensystemandneedaprofitfromthe saleofdrugsandrecompensetorecoupthecostofresearch.Oneimportantchallenge isthereforetoensurethatfor-profitcompaniescontinuetoworkinpartnershipsand providedrugsandvaccinestothepoorestcountriesoftheworld,andinthesamespirit whichmotivatesthesealliancesandtheobjectivesforwhichitwasinitiated. Analternativeapproachtoobtainingmuchneededdrugsataffordableprice,isforpoor countriestonegotiatewithindividualpharmaceuticalcompaniesbasedinEuropeand NorthAmerica.Newdrugs,especiallyantiretrovirals,thatimprovethequalityoflifeof thoselivingwithAIDSarenowavailableforpatientsinindustrializedcountries;treatment canalsopreventthetransmissionofHIVfrommotherstoinfantsinalmost70%ofcases. However,thepriceofsuchdrugsconstituteaheavyburdenonthealreadydepleted financialresourcesavailabletotheministriesofhealth.Fortheirpart,pharmaceutical companiesrecognizethattheycanbenefitfrompreferentialpricingagreementswith countriesthatwouldotherwisenotbeabletopurchasethedrugs.Withtheassistance oftheRegionalOffice,Lebanon,MoroccoandTunisiahavereachedagreementswith pharmaceuticalcompaniestosupplyhealthministrieswithantiretroviraldrugsatmuch reducedprices.OthercountriesintheRegionarepreparingtonegotiatewithdrug companiesforaccesstoaffordableantiretroviraldrugs.

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Theconceptof partnershipneedsto beclearly understood,forit requiresmutual trustandopenness inordertoplanand carryoutjoint programmes.

Withtheassistance oftheRegional Office,Lebanon, MoroccoandTunisia havereached agreementswith pharmaceutical companiestosupply healthministries withantiretroviral drugsatmuch reducedprices.

Communityparticipation CommunityparticipationisaneglectedaspectofHealthforAll.Withoutit,peoplewill notbeawareoftheexistenceofprotectiveservicesandwillnotusethem.Members ofthepublicneedtoexpresswhattheyperceivearetheirhealthneeds,andcontribute towardsmeetingtheseneeds. Thechallengeistoinvolveallsectionsofthecommunity—women,menandchildren, richandpoor—usingtheirskillsandknowledge,recognizingtheirneeds,andworking withthemtoidentifyandovercomelocalhealthrisks. Womenareusuallyresponsibleforthehealthoffamilymembers,especiallyyoung childrenwhoaremostvulnerabletocommunicablediseases.Theyarethuswellplaced tobeinvolvedintheservicesofferedbylocalhealthfacilities.However,outreach programmesintheRegionareusuallyweak. InsomepartsoftheRegion,mothersdonotunderstandthattheirchildrenneed immunizations.Insteadtheytendtothinkthatthisissomethingforcedonthembythe government,whichcanenforceitswillbyrequiringimmunizationcertificatesforchildren beforetheystartschool.Toovercomethisidea,thegovernmentcaninvolvelocal womenintheprogramme,ratherthanseethemaspassiveacceptorsofservices. Theycantrainlocalwomentoimmunizechildrensafely,keeprecordsandpersuade theirpeerstoparticipateinimmunizationprogrammes.

StudiesintheRegionshowthatwomenoftenneglecttheirownhealth,andmaynot beallowedbytheirhusbandsorfatherstovisithealthcentresontheirown.Also, women’shealthneedsaredifferentfromthoseofmen.Manyprimaryhealthcareworkers intheRegionarewomen,andarethuswellplacedtoreachouttootherwomen. However,currentlytheymakelittleattempttoencouragewomentobeinvolved inactivitiesrelatedtotheirownhealth,andthehealthoftheirfamilies. TherearefewexamplesintheRegionofpoorpeoplebeinginvolvedinhealthissuesin partnershipwiththepublichealthsystemornongovernmentalorganizations.Thepoor, whocompriseathirdorahalfofthepopulationinsomecountriesoftheRegion,are themostvulnerabletocommunicablediseases.Theyliveinsocialandeconomicisolation fromothermembersofthesociety.Theyareoftenbeyondthereachofthehealth system.Somemaybenomadicorsemi-nomadic,seekingoutalivingontheedgeof agriculturalsettlements. Largenumbersofpoorpeopleliveincrowdedsquattersettlementsinandaroundthe mega-citiesoftheRegion(suchasCairowith16million,Karachi12million,andTeheran with10millionpeople).Theyareusuallybeyondthereachofurbanhealthandmunicipal services,suchaswater,sanitationandgarbagecollection.Theovercrowdingandpoor sanitationarefavorableconditionsforincreasingsusceptibilitytoinfectionandfostering spreadofdiseases.

Insomepartsofthe Region,mothersdo notunderstandthat theirchildrenneed immunizations. Insteadtheytendto thinkthatthisis somethingforcedon thembythe government.

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Thechallengeisto involveallsections ofthecommunity— women,menand children,richand poor—usingtheir skillsand knowledge, recognizingtheir needs,andworking withthemtoidentify andovercomelocal healthrisks. Therearefew examplesinthe Regionofpoor peoplebeing involvedinhealth issuesinpartnership withthepublic healthsystemor nongovernmental organizations.