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W O R L D HEALTH ORGANIZATION EB74/2

O R G A N I S A T I O N M O N D I A L E D E L A S A N T É 2 A p r i l 1984

EXECUTIVE BOARD

Seventy-fourth Session Provisional agenda item 5

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REPORT ON MEETINGS OF EXPERT COMMITTEES A N D STUDY GROUPS Report b y the Director-General

The Director-General submits this report on four meetings of expert committees^- and one meeting of a study groups whose reports h a v e been prepared in English and French since the seventy-third session of the Executive Board.^

The meetings of four expert committees and one study group and their reports are reviewed h e r e u n d e r , in the following order;

1. THE LEISHMANIASES

Report of a WHO Expert Committee 2 . CARDIOMYOPATHIES

Report of a W H O Expert Committee 3., BIOLOGICAL STANDARDIZATION

Thirty-fourth report of the WHO Expert Committee on Biological Standardization 4 . CHEMISTRY AND SPECIFICATIONS OF PESTICIDES

Eighth report of the WHO Expert Committee on Vector Biology and Control

5 . MENTAL HEALTH CARE IN DEVELOPING COUNTRIES: A CRITICAL APPRAISAL OF RESEARCH FINDINGS

Report of a WHO Study Group

1 In compliance with Regulation 4.23 of the Regulations for Expert Advisory Panels and Committees (WHO Basic Documents, 34th e d . , 1984, p . 9 9 ) .

2 . In conformity with resolution EB17.R13, operative paragraph 4 .

о For easy reference, copies of these r e p o r t s , either in their final form or in p r o o f , are annexed to this report (for members of the Executive Board o n l y ) .

E B 7 4 / 2 page 2

1 . THE L E I S H M A N I A S E S

R e p o r t of a WHO E x p e r t C o m m i t t e e G e n e v a , 10-16 N o v e m b e r 1 9 8 21

1.1 B a c k g r o u n d

A g r o w i n g a w a r e n e s s of the importance of the leishmaniases as a public health problem h a s b e e n shown b y m a n y M e m b e r States in recent y e a r s . T h e increase and spread of this group of d i s e a s e s h a v e p a r t i c u l a r l y affected r u r a l p o p u l a t i o n s , m i g r a n t w o r k e r s , travellers and c h i l d r e n .

T h e c o m p l i c a t e d n a t u r e and w i d e d i v e r s i t y of the epidemiology and clinical

m a n i f e s t a t i o n s of the d i s e a s e s and of the specific approaches to c o n t r o l required for each of these d i s e a s e s a r e a serious p r a c t i c a l o b s t a c l e to the h e a l t h services in selecting the a p p r o p r i a t e c o n t r o l s t r a t e g y . T h e E x p e r t C o m m i t t e e¹ s m e e t i n g was the first held on the

l e i s h m a n i a s e s and its r e p o r t is the first on this subject in the W H O T e c h n i c a l Report S e r i e s . 1.2 T h e report

T h e r e p o r t gives a c o m p r e h e n s i v e and systematic account of; (1) the various forms of d i s e a s e caused by L e i s h m a n i a in m a n ; (2) available information on geographic distribution in M e m b e r States； (3) the public h e a l t h importance for each region; (4) a review of parasite t a x o n o m y9 i d e n t i f i c a t i o n m e t h o d s , and standards； (5) r e s e r v o i r animals and criteria for i n c r i m i n a t i n g suspected r e s e r v o i r h o s t s ; (6) criteria for the identification of v e c t o r s , their b i o l o g y , p o p u l a t i o n d y n a m i c s , v e c t o r i a l ability and incrimination； (7) e p i d e m i o l o g y , i n c l u d i n g t r a n s m i s s i o n seasons and sites and the factors influencing transmission rates；

(8) s u r v e i l l a n c e m e t h o d s for each element in the transmission cycle； (9) control m e t h o d s , i n c l u d i n g d i a g n o s t i c and treatment t e c h n i q u e s , sandfly c o n t r o l , and reservoir control;

(10) c o n t r o l s t r a t e g i e s , including g u i d e l i n e s for the c o n t r o l of the various forms of diseases； and (11) training and research r e q u i r e m e n t s .

T h e r e p o r t p r o v i d e s c o m p r e h e n s i v e standards for all the subjects related to

l e i s h m a n i a s i s c o n t r o l • For a subject so v a s t and d i v e r s e , the Committee has succeeded in m a k i n g it as c o n c i s e as p o s s i b l e .

T h e C o m m i t t e e w a s fully aware of the risk of including incomplete data on distribution in the r e p o r t . N e v e r t h e l e s s , it decided to do so as a first step and as a stimulus in order to obtain m o r e c o m p l e t e information from the endemic areas• In order to identify parasite s t o c k s , the C o m m i t t e e adopted a four-element code indicating; (1) the type of h o s t animal or v e c t o r from w h i c h the strain w a s isolated; (2) the country w h e r e isolation was made；

(3) the y e a r of isolation； and (4) the laboratory d e s i g n a t i o n . It recommended that this code b e used i n t e r n a t i o n a l l y . It also listed the relatively few proven vectors of h u m a n l e i s h m a n i a s i s . T h e r e p o r t emphasizes that strict standards should be m e t before reservoir animals or v e c t o r s are i n c r i m i n a t e d , since control on the b a s i s of m e r e assumption is often i n e f f e c t i v e , c a n be c o s t l y , and m a y cause unnecessary damage to the e n v i r o n m e n t . The report d i s c u s s e s t e c h n i c a l s u r v e i l l a n c e m e t h o d s such as sampling and t r a p p i n g and methods for p o p u l a t i o n s u r v e i l l a n c e . T h e r e v i e w of treatment regimens based on the latest advances in p h a r m a c o l o g y and t o x i c o l o g y provides long-awaited standard guidelines for the safe use of a n t i l e i s h m a n i a l d r u g s .

T h e C o m m i t t e e laid special emphasis on the need for developing diagnostic techniques suitable for field u s e , such as those r e c e n t l y developed for A f r i c a n t r y p a n o s o m i a s i s . The annexes d e s c r i b e p r a c t i c a l t e c h n i q u e s , t h e isolation and h a n d l i n g of p a r a s i t e s , and standards for r e a d i n g skin r e a c t i o n .

1.3 T h e r e c o m m e n d a t i o n s

W i t h regard to the public h e a l t h a s p e c t s , the C o m m i t t e e recommended that visceral

leishmaniasis should be m a d e a n o t i f i a b l e disease as a m e a n s of early recognition and control

1 WHO T e c h n i c a l Report S e r i e s , N o . 701， 1 9 8 4 .

E B 7 4 / 2 p a g e 3 of e p i d e m i c s . T h e n e e d for e n d e m i c c o u n t r i e s to m a i n t a i n a d e q u a t e s t o c k s of d r u g s and e n s u r e their a p p r o p r i a t e u s e is s t r e s s e d as a p r i o r i t y . T h e C o m m i t t e e r e c o m m e n d e d that M e m b e r

S t a t e s s h o u l d i n t e n s i f y the e x c h a n g e of i n f o r m a t i o n , p a r t i c u l a r l y on e p i d e m i o l o g i c a l findings and c o n t r o l a c t i v i t i e s .

T h e t e c h n i c a l r e c o m m e n d a t i o n s c o n c e r n d i a g n o s i s , t r e a t m e n t , v e c t o r s a m p l i n g , and the use of s t a n d a r d m e t h o d s for p a r a s i t e l a b e l l i n g and i d e n t i f i c a t i o n (see a b o v e ) . O n r e s e a r c h and t r a i n i n g , the C o m m i t t e e r e c o m m e n d e d the d e v e l o p m e n t of n e w d r u g s and d i a g n o s t i c t e c h n i q u e s and l o n g - t e r m s t u d i e s in e p i d e m i o l o g y as h i g h e s t p r i o r i t i e s and s u p p o r t e d the r e s e a r c h p r i o r i t i e s c h o s e n b y the S c i e n t i f i c W o r k i n g G r o u p on L e i s h m a n i a s i s of the S p e c i a l P r o g r a m m e for R e s e a r c h and T r a i n i n g in T r o p i c a l D i s e a s e s . In the field of t r a i n i n g , the C o m m i t t e e c o n s i d e r e d the t r a i n i n g of n a t i o n a l e p i d e m i o l o g i s t s to be the m o s t u r g e n t need for l e i s h m a n i a s i s c o n t r o l .

1.4 S i g n i f i c a n c e for public h e a l t h and i m p l i c a t i o n s for the O r g a n i z a t i o n ' s p r o g r a m m e T h e m e e t i n g w a s c o n v e n e d to w o r k out b a s i c p r a c t i c a l g u i d e l i n e s for c o l l e c t i n g the e s s e n t i a l e p i d e m i o l o g i c a l i n f o r m a t i o n and for the d e s i g n of c o n t r o l s c h e m e s . It was the first s t e p t o w a r d s d e f i n i n g a p p r o p r i a t e s t r a t e g i e s for each s p e c i f i c e n d e m i c s i t u a t i o n . It is h o p e d that the C o m m i t t e e1 s o v e r a l l u p - t o - d a t e r e v i e w of e p i d e m i o l o g i c a l , p a r a s i t o l o g i c a l , v e c t o r i a l , p a t h o l o g i c a l and c o n t r o l a s p e c t s w i l l p r o v i d e a s t i m u l u s for o b t a i n i n g b e t t e r b a s e - l i n e d a t a , p a r t i c u l a r l y o n the d i s t r i b u t i o n and p r e v a l e n c e of l e i s h m a n i a s e s in e a c h M e m b e r S t a t e . O n c e this type of i n f o r m a t i o n h a s b e e n c o l l e c t e d , W H O w i l l b e in a p o s i t i o n to p r e p a r e d e t a i l e d g u i d e l i n e s for the s p e c i f i c n e e d s of the public h e a l t h s e r v i c e s of the

e n d e m i c c o u n t r i e s in m o s t p a r t s of the w o r l d . 2 . C A R D I O M Y O P A T H I E S

R e p o r t of a W H O E x p e r t C o m m i t t e e G e n e v aэ 18-23 A p r i l 1 9 8 31

2 • 1 B a c k g r o u n d

C a r d i o m y o p a t h i e s a r e d e f i n e d as " h e a r t m u s c l e d i s e a s e s of u n k n o w n c a u s e " • In the c o n t e x t of the W H O l o n g - t e r m p r o g r a m m e for the p r e v e n t i o n and c o n t r o l of c a r d i o v a s c u l a r d i s e a s e s , this E x p e r t C o m m i t t e e was the f i r s t to d e a l s p e c i f i c a l l y w i t h this g r o u p of h e a r t d i s e a s e s . T h e y a f f e c t the p o p u l a t i o n s in b o t h d e v e l o p i n g and i n d u s t r i a l i z e d c o u n t r i e s • T h e r e i s , h o w e v e r , a lack of e p i d e m i o l o g i c a l i n f o r m a t i o n n e c e s s a r y for the a c c u r a t e a s s e s s m e n t of the e x t e n t of the p r o b l e m in d i f f e r e n t p a r t s of the w o r l d . This is

a t t r i b u t a b l e to lack of k n o w l e d g e , a lack of u n i f o r m t e r m i n o l o g y in the p a s t , and an a b s e n c e of a p p r o p r i a t e e p i d e m i o l o g i c a l m e t h o d s and t e c h n i q u e s n e e d e d for p o p u l a t i o n s t u d i e s . F o r t h e s e r e a s o n s the E x p e r t C o m m i t t e e w a s c o n v e n e d •

2.2 T h e r e p o r t

T h e r e p o r t of t h e E x p e r t C o m m i t t e e s t r e s s e s the n e e d to u s e a s t a n d a r d d e f i n i t i o n and c l a s s i f i c a t i o n of c a r d i o m y o p a t h i e s . It e n d o r s e s the c l a s s i f i c a t i o n e l a b o r a t e d by a W H O I n t e r n a t i o n a l S o c i e t y and F e d e r a t i o n of C a r d i o l o g y t a s k force in 1 9 8 0 . A c c o r d i n g to this task force " c a r d i o m y o p a t h i e s are h e a r t m u s c l e d i s e a s e s of u n k n o w n c a u s e " . H e a r t d i s e a s e s of k n o w n e t i o l o g y ( f o r m e r l y s e c o n d a r y c a r d i o m y o p a t h y ) are c l a s s i f i e d u n d e r " s p e c i f i c h e a r t m u s c l e d i s e a s e " .

T h e r e p o r t d i s c u s s e s the latest d a t a a v a i l a b l e on the e x t e n t of the p r o b l e m of i n d i v i d u a l c a r d i o m y o p a t h i e s in d i f f e r e n t p a r t s of the w o r l d , their p a t h o l o g y , the

h a e m o d y n a m i c c h a n g e s c a u s e d b y t h e m , d i a g n o s t i c m e t h o d s and c l i n i c a l a p p e a r a n c e , t r e a t m e n t , and p r o g n o s i s •

B e c a u s e of t h e limited k n o w l e d g e in m o s t of t h e s e a r e a s the r e p o r t d e a l s s y s t e m a t i c a l l y w i t h p r i o r i t i e s in r e s e a r c h . It also s t r e s s e s the u r g e n t n e e d for r e s e a r c h in r e l a t i o n to p r e v e n t i o n of t h e s e h e a r t d i s e a s e s .

1 WHO T e c h n i c a l R e p o r t S e r i e s , N o . 6 9 7 , 1 9 8 4 .

EB74/2 page 4

C o n c e r n i n g the specific h e a r t m u s c l e diseases (cardiomyopathies of k n o w n c a u s e ) , the report deals only w i t h those that are m o s t p r e v a l e n t or of special r e l e v a n c e b e c a u s e of their e t i o l o g y , g e o g r a p h i c a l d i s t r i b u t i o n , and similarities to c e r t a i n forms of c a r d i o m y o p a t h y . 2.3 T h e r e c o m m e n d a t i o n s

T h e Contraittee c o n s i d e r e d that systematic research on the etiology and n a t u r a l h i s t o r y of c a r d i o m y o p a t h i e s is e s s e n t i a l in both developed and d e v e l o p i n g c o u n t r i e s . The m a g n i t u d e of the p r o b l e m is at p r e s e n t obscured by the p a u c i t y of the i n f o r m a t i o n about their i n c i d e n c e , g e o g r a p h i c a l d i s t r i b u t i o n , and c a u s e s .

P o p u l a t i o n studies are also e s s e n t i a l and should be related to r e c o g n i t i o n of early cases• Simple d i a g n o s t i c techniques for c l i n i c a l w o r k or e p i d e m i o l o g i c a l studies a p p l i c a b l e to d e v e l o p i n g c o u n t r i e s should b e i d e n t i f i e d . A c t i v e c o l l a b o r a t i o n b e t w e e n r e s e a r c h

institutes at d i f f e r e n t levels in both industrialized and d e v e l o p i n g c o u n t r i e s should b e p r o m o t e d • Regional r e g i s t r i e s ensuring s t a n d a r d i z a t i o n of d i a g n o s i s should be e s t a b l i s h e d •

Research proposals d e a l i n g w i t h priority programmes are discussed specifically for each of the c a r d i o m y o p a t h i e s .

2.4 Significance for public h e a l t h and i m p l i c a t i o n s for the O r g a n i z a t i o n1s programme T h e r e p o r t , through its review of the p r e s e n t limited k n o w l e d g e of c a r d i o m y o p a t h i e s , provides an u p - t o - d a t e basis for further w o r k in this area of c a r d i o v a s c u l a r diseases and for e p i d e m i o l o g i c a l , c l i n i c a l and basic r e s e a r c h . It takes a p o s i t i v e a p p r o a c h , m a k e s

c o n s t r u c t i v e proposals for the introduction of a d e f i n i t i o n and c l a s s i f i c a t i o n of

c a r d i o m y o p a t h i e s , p u t s forward d e t a i l e d r e c o m m e n d a t i o n s for further r e s e a r c h , and examines present limitations in the p r e v e n t i o n and c o n t r o l of c a r d i o m y o p a t h i e s in p o p u l a t i o n s . O v e r a l l , it presents a c r i t i c a l b u t b a l a n c e d v i e w and thus is a good basis for planning any future w o r k of WHO in this f i e l d , w h i c h is r e l e v a n t to both d e v e l o p i n g and industrialized c o u n t r i e s •

3 . B I O L O G I C A L S T A N D A R D I Z A T I O N

T h i r t y - f o u r t h r e p o r t of the W H O E x p e r t C o m m i t t e e on B i o l o g i c a l Standardization G e n e v a , 27 September - 3 October 1 9 8 31~

3•1 Background

A t its thirty-fourth m e e t i n g , the W H O E x p e r t Committee on B i o l o g i c a l S t a n d a r d i z a t i o n reviewed the d e v e l o p m e n t s in b i o l o g i c a l r e f e r e n c e m a t e r i a l s that had taken place since its m e e t i n g in 1 9 8 2 . T h e r e w e r e 32 items for d i s c u s s i o n in the following groups of s u b s t a n c e s : antibiotics； antibodies； antigens ; blood products and related substances； and

e n d o c r i n o l o g i c a l s u b s t a n c e s . In a d d i t i o n , three sets of r e q u i r e m e n t s had b e e n formulated or amended and the r e p o r t s of two WHO informal c o n s u l t a t i o n s w e r e c o n s i d e r e d . One of these c o n s u l t a t i o n s examined the principles of the p r o d u c t i o n of b i o l o g i c a l s by r e c o m b i n a n t D N A techniques and the tests b y which the q u a l i t y c o n t r o l of such products m a y b e e f f e c t e d . At the other c o n s u l t a t i o n the importance of the use of intravenous immunoglobulins was discussed and the c h a r a c t e r i z a t i o n of the products enumerated with a v i e w to the formulation of

r e q u i r e m e n t s • 3.2 T h e report

It was noted that i n t e r n a t i o n a l standards and reference p r e p a r a t i o n s w e r e established for one a n t i b i o t i c , three a n t i g e n s , three blood p r o d u c t s , one e n d o c r i n o l o g i c a l substance and four m i s c e l l a n e o u s s u b s t a n c e s , and that c o l l a b o r a t i v e studies for the establishment of other reference m a t e r i a l s w e r e in p r o g r e s s . One a n t i g e n and one blood p r o d u c t w e r e d i s c o n t i n u e d •

1 WHO T e c h n i c a l Report S e r i e s , N o . 7 0 0 , 1 9 8 4 .

EB74/2 page 5 At the request of those responsible for the reduction of Rift Valley fever in sheep and cattle, and in v i e w of the availability of a safe, live attenuated virus (Smithburn strain), Requirements for Rift Valley Fever Vaccine (Live Attenuated) for Veterinary Use were

formulated.

A vaccine made from a mutant of Salmonella typhi (Ту 21a) and given by the oral route had been shown to be safe and, in a trial in E g y p t , to give protection against typhoid fever. Accordingly, Requirements for Typhoid Vaccine (Live A t t e n u a t e d , Ту 2 1 a , Oral) have been formulated•

The Requirements for Diphtheria T o x o i d , Pertussis V a c c i n e , Tetanus Toxoid and Combined Vaccines were amended to take into consideration technical developments since they were first formulated•

3.3 Considerations and recommendations

For 20 years two categories of standard preparations have been used to define

international units of activity, i . e . , international biological standards and international biological reference preparations• The Committee reviewed the situation and decided t h a t , in the future, for all preparations that had been subjected to an international collaborative assay and on the basis of which an international unit had been defined to express a c t i v i t y , a single category should be u s e d , n a m e l y , international biological standards. It would

nevertheless be important to retain the category of international reference preparations for substances that did not define an international u n i t .

Important advances have been m a d e in the measurement of potency of rabies vaccines m a d e in cell cultures. Comparison of a radial diffusion technique with that of the classical test of immunizing mice and challenging them with virulent virus has shown that the in vitro test has a much greater reproducibility and accuracy• The in vitro m e t h o d , therefore, was used

for the comparison of the potency of the fourth international standard with that of the third standard for the purpose of assigning an international unit of activity to the fourth

standard•

In view of the importance of the availability of a standardized tuberculin for use in measuring the reaction pattern of different populations to tuberculosis, the Committee felt that there should be a review of the standards available for this purpose and requested the Secretariat to arrange a consultation to discuss this m a t t e r .

The standardization of the gonadotrophins, folliele-stimulating hormone (FSH) and luteinizing hormone (LH)， is complex. Efforts h a v e been made to maintain the continuity of the units of activity of these hormones throughout the various replacements of FSH or L H , whether obtained from pituitary or urinary extracts and measured by bioassays or

immunoassays• Confusion has arisen in the expression of potency because scientists are requested by different journals to express their data in different w a y s . In oraer to clarify the situation, therefore, the Committee requested the National Institute for Biological Standards and Control, L o n d o n , to assemble the relevant data on the international

gonadotrophin reference materials and to alert the editors of the relevant journals to their availability in order to obtain uniformity in the expression of assay r e s u l t s .

The availability of a cheap and readily available live attenuated Rift Valley fever vaccine for use in cattle h a s been needed for some y e a r s . The Committee1 s consideration of requirements for such a vaccine in order to have internationally acceptable norms for its production and control has important implications, particularly in endemic areas•

Since a vaccine prepared from a mutant of Salmonella typhi (Ту 21a) was shown to protect against typhoid fever in an endemic area, the Committee considered that requirements for the production and control of such a vaccine were important• They accordingly reviewed and adopted the proposed requirements•

3.4 Significance for public health and implications for the O r g a n i z a t i o n1s programme The use of a rapid, cheap and more accurate method of assaying the glycoprotein of rabies vaccines will give greater accuracy in the immunizing antigen contained in the vaccine

EB74/2 page 6

arid thereby increase confidence in its u s e . This is of particular importance in vaccines that m u s t h a v e at least 2.5 I . U . per dose before they may be used in a six-dose schedule in subjects known to h a v e been bitten by a rabid animal. The future production of rabies v a c c i n e s , commonly grown in the brains of animals, is directed towards the use of cell cultures for the growth of the virus and the new method of potency assay is particularly suited to such vaccines•

Rift Valley fever is a disease common in cattle in Africa but it is rarely transmitted to m a n . In 1977, h o w e v e r , the disease infected man in Egypt and became a public health h a z a r d . A c c o r d i n g l y , reduction of the disease in cattle was recommended, but it was recognized that this was dependent upon a cheap vaccine being produced and made readily available for all cattle and sheep. The use of the Smithburn strain offered such an

o p p o r t u n i t y . To enable a live attenuated vaccine prepared from this strain to be used on a wide scale in many c o u n t r i e s , the requirements were formulated to assist in its acceptability when crossing national borders. The acceptance of such requirements should lead to a

widespread use of the vaccine arid a marked reduction in the d i s e a s e , leading to greater production of food in countries in Africa in which the disease is endemic•

Vaccines produced for use against typhoid fever have been under investigation for over 40 years and some have given good protection. However, none has been shown to be entirely

s a t i s f a c t o r y , particularly with respect to reactivity in m a n . The finding that a mutant of Salmonella typhi (Ty 21a) given by the oral route in an endemic area in Egypt gave protection against the disease was of importance. So that vaccines conformed to uniform standards, t h e r e f o r e , requirements were formulated. If a vaccine meeting such requirements is shown to be protective in other countries in controlled clinical trials, a big step forward in public health w i l l h a v e been m a d e .

Immunoglobulins prepared by methods by which they do not give rise to reactions when given by the intravenous route represent a significant advance in public h e a l t h . Such preparations are more rapidly available to the body and more immunoglobulins reach their t a r g e t . Their use is increasing rapidly and the Committee, after reviewing the importance of their u s e , recommended that requirements should be formulated for the control of

immunoglobulins used in this w a y .

The standardization of tuberculins continues to pose a p r o b l e m . Immunization programmes against tuberculosis rely upon the detection of sensitivity to tuberculin as a measure of the efficacy of the BCG vaccine u s e d . It is important, therefore, to h a v e tuberculins available internationally that have been standardized by a uniform method and this problem will

continue to be investigated. On the other h a n d , some countries use tuberculins to measure the immune status of specific age-groups to tuberculosis.

The expression of activity of human gonadotrophins is also important. Much progress has been m a d e in the purification of the follicle-stimulating hormone (FSH) and luteinizing h o r m o n e (LH), and with each new finding the international standard has been changed, whether measured by in v i t r o or in vivo m e t h o d s . For these h o r m o n e s , with such powerful activity, it

is critical that a correct and accurately measured dose be u s e d . The Secretariat was asked to clarify the present confusion in the measurement of the potency of these substances and to take steps towards the adoption of a universal method for the reporting of assay results in international u n i t s .

4 . CHEMISTRY AND SPECIFICATIONS OF PESTICIDES

Eighth report of the WHO Expert Committee on Vector Biology and Control G e n e v a , 8-14 November 1 9 8 31

4•1 Background

Since its e s t a b l i s h m e n t , the Organization has periodically issued specifications for pesticides used in public health programmes. It has been recognized that this supports Member States in the purchase of pesticides of defined quality which should guarantee their

1 WHO Technical Report Series, N o . 699， 1984.

E B 7 4 / 2 page 7 e f f e c t i v e n e s s and s a f e t y w h e n used as r e c o m m e n d e d in v e c t o r c o n t r o l p r o g r a m m e s • T h e same p e s t i c i d e s u s u a l l y h a v e a g r i c u l t u r a l a p p l i c a t i o n s in a v a r i e t y of f o r m u l a t i o n s and the s p e c i f i c a t i o n s are t h e r e f o r e i n c r e a s i n g l y b e i n g h a r m o n i z e d w i t h those of F A O •

In the c o n t e x t of the W H O P e s t i c i d e E v a l u a t i o n S c h e m e , s p e c i f i c a t i o n s for p e s t i c i d e s of p r o v e n e f f i c a c y in p u b l i c h e a l t h are d r a f t e d in c o l l a b o r a t i o n w i t h m a n u f a c t u r e r s . They are t h e n issued as i n t e r i m s p e c i f i c a t i o n s in u n p u b l i s h e d d o c u m e n t s and the m e t h o d s o u t l i n e d are s u b m i t t e d to c o l l a b o r a t i v e t e s t i n g u n d e r the a u s p i c e s of the C o l l a b o r a t i v e I n t e r n a t i o n a l P e s t i c i d e s A n a l y t i c a l C o u n c i l ( C I P A C ) • In r e c e n t y e a r s an e x p e r t c o m m i t t e e h a s m e t every sixth y e a r to c o n s i d e r i n t e r i m s p e c i f i c a t i o n s w h i c h h a v e b e e n s a t i s f a c t o r i l y t e s t e d , and to r e c o m m e n d t h e i r a d o p t i o n . T h e y are t h e n i n c l u d e d in the m a n u a l on S p e c i f i c a t i o n s for p e s t i c i d e s u s e d in p u b l i c h e a l t h , c u r r e n t l y in its fifth e d i t i o n . A r e v i e w of the

d i s t r i b u t i o n of this m a n u a l h a s shown that it is v e r y w i d e l y u s e d , e s p e c i a l l y in d e v e l o p i n g c o u n t r i e s . M o r e t h a n 500 p u r c h a s e r s h a v e r e t u r n e d a card r e q u e s t i n g that the i n t e r i m s p e c i f i c a t i o n s b e sent to t h e m .

I n a d d i t i o n to r e c o m m e n d i n g s p e c i f i c a t i o n s for t e c h n i c a l p r o d u c t s and f o r m u l a t i o n s a d a p t e d for p u b l i c h e a l t h u s e , the E x p e r t C o m m i t t e e a l s o c o n s i d e r s w i d e r i s s u e s such as the a v a i l a b i l i t y of f a c i l i t i e s for t e s t i n g , the c h e m i s t r y of p e s t i c i d e s , and p a c k a g i n g and l a b e l l i n g .

4 . 2 T h e r e p o r t

T h e E x p e r t C o m m i t t e e first c o n s i d e r e d n e w trends in v e c t o r c o n t r o l and their p o s s i b l e i m p l i c a t i o n s for p e s t i c i d e u s e , f o r m u l a t i o n s and p a c k a g i n g a n d , c o n s e q u e n t l y ,

s p e c i f i c a t i o n s • H u m a n , s o c i o e c o n o m i c , b i o l o g i c a l , p o l i t i c a l and e n v i r o n m e n t a l factors are i n f l u e n c i n g the m a n a g e m e n t of v e c t o r c o n t r o l p r o g r a m m e s , w h i c h w e r e i n i t i a l l y v e r t i c a l but n o w tend to b e i n c l u d e d in p r o g r a m m e s of p r i m a r y h e a l t h c a r e . R e f e r e n c e was m a d e to c o m p l e m e n t a r y c o n t r o l m e t h o d s , i n c l u d i n g the u s e of b i o l o g i c a l c o n t r o l a g e n t s and

e n v i r o n m e n t a l m o d i f i c a t i o n or m a n a g e m e n t , as part of i n t e g r a t e d c o n t r o l of v e c t o r s t o g e t h e r w i t h the u s e of p e s t i c i d e s w h e r e n e c e s s a r y .

T h e C o m m i t t e e t o o k n o t e of the p o t e n t i a l w i t h i n d e v e l o p i n g c o u n t r i e s for the p h y s i c o c h e m i c a l a n a l y s i s of p e s t i c i d e s • A b r i e f i n v e n t o r y of the m a i n e q u i p m e n t and

e s s e n t i a l r e a g e n t s for m o d e r n a n a l y t i c a l m e t h o d s w a s p r o d u c e d for l a b o r a t o r i e s w i t h limited r e s o u r c e s • T h e C o m m i t t e e s t r e s s e d the n e e d to s t a n d a r d i z e e q u i p m e n t and o p e r a t i n g c o n d i t i o n s as far as p o s s i b l e .

T h e C o m m i t t e e t h e n r e v i e w e d the e x i s t i n g s p e c i f i c a t i o n s and s u g g e s t e d a m e n d m e n t s w h e r e a p p r o p r i a t e . It r e c o m m e n d e d that n e w a n a l y t i c a l m e t h o d s should be i n c l u d e d in the m a n u a l , p r o v i d e d that t h e s e w e r e found to b e s u p e r i o r to e x i s t i n g m e t h o d s and h a d b e e n the subject of t r i a l s by s e v e r a l c o l l a b o r a t i n g l a b o r a t o r i e s . N e w f o r m u l a t i o n s of o l d e r c o m p o u n d s c u r r e n t l y u s e d in v e c t o r c o n t r o l should a l s o b e i n c l u d e d • O n the o t h e r h a n d , some s u b s t a n c e s which h a v e b e e n s u p e r s e d e d should n o w be d e l e t e d , as w e l l as some t e s t i n g m e t h o d s that are m u c h

less a c c u r a t e than the n e w a n a l y t i c a l t e c h n i q u e s .

T h e C o m m i t t e e rioted the c o l l a b o r a t i o n w i t h o t h e r i n t e r n a t i o n a l o r g a n i z a t i o n s , such as F A O , C I P A C and the A s s o c i a t i o n of O f f i c i a l A n a l y t i c a l C h e m i s t s ( A O A C ) in the e s t a b l i s h m e n t of s p e c i f i c a t i o n s and the f o r m u l a t i o n of u n i v e r s a l l y a c c e p t e d a n a l y t i c a l m e t h o d s . T h e

i m p o r t a n c e of this c l o s e and c o n t i n u o u s c o l l a b o r a t i o n for the h a r m o n i z a t i o n of d i f f e r e n t s p e c i f i c a t i o n s w a s s t r e s s e d .

4 . 3 T h e r e c o m m e n d a t i o n s

R e c o m m e n d a t i o n s to M e m b e r States

Since m o d e r n a n a l y t i c a l t e c h n i q u e s r e q u i r e some i n v e s t m e n t for the p u r c h a s e of e s s e n t i a l e q u i p m e n t , g o v e r n m e n t s should c o n s i d e r c o m b i n i n g their r e s o u r c e s and t h e i r e q u i p m e n t for p e s t i c i d e a n a l y s e s w i t h i n the country； thus the v a r i o u s p a r t i e s i n v o l v e d m a y c o l l a b o r a t e m o r e e f f e c t i v e l y , e v e n if they b e l o n g to s e v e r a l m i n i s t r i e s .

E B 7 4 / 2 p a g e 8

T h e C o m m i t t e e n o t e d t h e c o n t i n u e d u s e m a d e b y some M e m b e r States of the s y s t e m e s t a b l i s h e d in 1950 u n d e r w h i c h g o v e r n m e n t s are a b l e to p u r c h a s e p e s t i c i d e s on a

r e i m b u r s e m e n t b a s i s w i t h the t e c h n i c a l c o l l a b o r a t i o n of the O r g a n i z a t i o n . It r e c o m m e n d e d that W H O should r e m i n d all S t a t e s of this p r o c e d u r e and that g o v e r n m e n t s n o t a l r e a d y d o i n g so should c o n s i d e r u s i n g this s y s t e m for the p u r c h a s e of large q u a n t i t i e s of p e s t i c i d e s for p u b l i c h e a l t h u s e .

R e c o m m e n d a t i o n s to W H O

In m a n y d e v e l o p i n g c o u n t r i e s there a r e n o l a b o r a t o r i e s a b l e to u n d e r t a k e p e s t i c i d e a n a l y s i s and q u a l i t y c o n t r o l . C e r t a i n c e n t r e s w i t h the r e q u i s i t e e q u i p m e n t and s p e c i a l i s t s should t h e r e f o r e b e d e s i g n a t e d as W H O r e g i o n a l or s u b r e g i o n a l c e n t r e s ; t h e s e c e n t r e s c o u l d b e s t r e n g t h e n e d and s e r v e as f o c a l p o i n t s for r e s e a r c h and for the t r a i n i n g of c h e m i s t s and e q u i p m e n t m a i n t e n a n c e w o r k e r s .

R e g a r d i n g the m e a s u r e m e n t of active i n g r e d i e n t s , W H O should e n c o u r a g e the u s e of the a n a l y t i c a l m e t h o d s r e c o m m e n d e d b y C I P A C a n d A O A C . It should t h e r e f o r e r e v i s e the m e t h o d s h i t h e r t o r e c o m m e n d e d in o r d e r to a c h i e v e h i g h e r p r e c i s i o n in m e a s u r e m e n t , g r e a t e r

s e n s i t i v i t y , and b e t t e r r e p r o d u c i b i l i t y , so as to f a c i l i t a t e h a n d l i n g o p e r a t i o n s a n d , if p o s s i b l e , to r e d u c e t h e c o s t of a n a l y s e s .

I n a d d i t i o n , t h e C o m m i t t e e m a d e m a n y t e c h n i c a l r e c o m m e n d a t i o n s c o n c e r n i n g h e a t s t a b i l i t y t r e a t m e n t , t o l e r a n c e limits for the a c t i v e - i n g r e d i e n t c o n t e n t in f o r m u l a t i o n s , s p e c i f i c a t i o n s c o n c e r n i n g i m p u r i t i e s , and s u s p e n s i b i l i t y t e s t s . In m o s t i n s t a n c e s these r e c o m m e n d a t i o n s w e r e m a d e w i t h the o b j e c t of h a r m o n i z i n g t h e s p e c i f i c a t i o n s of WHO and of F A O . R e s e a r c h

should b e c a r r i e d o u t to p r o v i d e further d a t a o n some p r o b l e m s that are n o t y e t r e s o l v e d . W H O should p u b l i s h a sixth e d i t i o n of the m a n u a l of s p e c i f i c a t i o n s as soon as p o s s i b l e , t a k i n g into a c c o u n t the c h a n g e s s u m m a r i z e d a b o v e . T h e r e p o r t s p e c i f i e s w h a t should b e i n c l u d e d in the m a n u a l in a d d i t i o n to t h e e x i s t i n g s p e c i f i c a t i o n s • F u r t h e r i n t e r i m

s p e c i f i c a t i o n s s h o u l d b e e s t a b l i s h e d for a c e r t a i n n u m b e r of s u b s t a n c e s and f o r m u l a t i o n s of i n s e c t i c i d e s , m o l l u s c i c i d e s , r e p e l l e n t s , and b i o l o g i c a l a g e n t s , as s o o n as their u s e b e c o m e s w i d e s p r e a d and t e c h n i q u e s for the m e a s u r e m e n t of their p h y s i c o c h e m i c a l c h a r a c t e r i s t i c s h a v e b e e n d e v i s e d .

T h e p a c k a g i n g of p e s t i c i d e s should c o r r e s p o n d to t h e s p e c i f i c a t i o n s laid d o w n by W H O and the l a b e l l i n g of p a c k a g e s should include the d a t e of m a n u f a c t u r e or f o r m u l a t i o n a n d , if p o s s i b l e , a n e x p i r y d a t e .

R e c o m m e n d a t i o n s to F A Q

S o m e f u r t h e r h a r m o n i z a t i o n b e t w e e n F A O and W H O s p e c i f i c a t i o n s is felt to b e n e c e s s a r y for c e r t a i n p e s t i c i d e s which* are of joint i n t e r e s t . F A O should u s e s o m e of the tests that a p p e a r in the W H O s p e c i f i c a t i o n s •

H a r m o n i z a t i o n w a s a l s o r e c o m m e n d e d w i t h r e s p e c t to F A O and W H O s u s p e n s i b i l i t y tests of w a t e r - d i s p e r s i b l e p o w d e r s u s i n g w a t e r of d i f f e r e n t d e g r e e s of h a r d n e s s .

4 . 4 S i g n i f i c a n c e for p u b l i c h e a l t h and i m p l i c a t i o n s for the O r g a n i z a t i o n1s p r o g r a m m e T h e r e p o r t c o n s i d e r s n e w a p p r o a c h e s in v e c t o r c o n t r o l and their i m p l i c a t i o n s for the s c r e e n i n g of n e w i n s e c t i c i d e s and for t h e d e v e l o p m e n t of s p e c i f i c a t i o n s for n e w c o m p o u n d s and their f o r m u l a t i o n s . It a l s o s t r e s s e s t h e n e e d for m o r e a c c u r a t e m e t h o d s of a n a l y s i s l e a d i n g to the i d e n t i f i c a t i o n of the a c t i v e i n g r e d i e n t and of p o s s i b l e i m p u r i t i e s w h i c h m a y m o d i f y the safety of the p r o d u c t s .

It u n d e r l i n e s the n e e d to s t r e n g t h e n s u p p o r t to c o u n t r i e s t h r o u g h :

- t h e e s t a b l i s h m e n t of r e g i o n a l or s u b r e g i o n a l l a b o r a t o r i e s , fully e q u i p p e d for the q u a l i t y c o n t r o l of p e s t i c i d e s and w e l l s t a f f e d by trained p e r s o n n e l able to p a r t i c i p a t e in the t r a i n i n g of n a t i o n a l s p e c i a l i s t s ;

E B 7 4 / 2 p a g e 9 - t h e d i s s e m i n a t i o n of s p e c i f i c a t i o n s b y the p u b l i c a t i o n of a n e w e d i t i o n of the m a n u a l on S p e c i f i c a t i o n s for p e s t i c i d e s u s e d in p u b l i c h e a l t h , and b y i s s u i n g i n t e r i m

s p e c i f i c a t i o n s for c o m p o u n d s of p u b l i c i n t e r e s t w h i c h a p p e a r b e t w e e n e x p e r t c o m m i t t e e m e e t i n g s , or for the d i f f u s i o n of n e w a n a l y t i c a l methods；

- c o l l a b o r a t i o n with M e m b e r States in the p u r c h a s e of l a r g e q u a n t i t i e s of p e s t i c i d e s o n a r e i m b u r s e m e n t b a s i s .

5 . M E N T A L H E A L T H C A R E IN D E V E L O P I N G COUNTRIES： A C R I T I C A L A P P R A I S A L OF R E S E A R C H F I N D I N G S R e p o r t of a W H O Study G r o u p

Geneva， 15-21 S e p t e m b e r 1 9 8 11

5•1 B a c k g r o u n d

T h e I n t e r n a t i o n a l C o n f e r e n c e on P r i m a r y H e a l t h C a r e at A l m a - A t a ( 1 9 7 8 ) r e c o m m e n d e d that the p r o m o t i o n of m e n t a l h e a l t h should b e o n e of the e l e m e n t s of p r i m a r y h e a l t h c a r e . M e n t a l h e a l t h c a r e h a s in fact three i m p o r t a n t c o m p o n e n t s w h i c h are r e l e v a n t to the e s s e n t i a l

e l e m e n t s of p r i m a r y h e a l t h c a r e . F i r s t , t r e a t m e n t should be p r o v i d e d for m e n t a l d i s o r d e r s , w h i c h h a v e b e e n d e m o n s t r a t e d to b e c o m m o n t h r o u g h o u t the w o r l d • S e c o n d , m e n t a l h e a l t h

p r o g r a m m e s should c o n t r i b u t e to the p r o v i s i o n of c a r e t h r o u g h o u t the h e a l t h s e c t o r b y e n s u r i n g that the p s y c h o l o g i c a l d i m e n s i o n is taken into a c c o u n t b y all h e a l t h w o r k e r s • F i n a l l y , the m e n t a l h e a l t h p r o g r a m m e s should b e a c t i v e l y i n v o l v e d in the p r o m o t i o n of m e n t a l w e l l - b e i n g . It is on a c c o u n t of the two latter c o m p o n e n t s that the p r o m o t i o n of m e n t a l h e a l t h was r e c o m m e n d e d as a s e p a r a t e e l e m e n t in p r i m a r y h e a l t h c a r e at the A l m a - A t a

C o n f e r e n c e . T h e r e s p o n s i b i l i t y for the p r o v i s i o n of all three of t h e s e c o m p o n e n t s u s u a l l y falls u p o n m e n t a l h e a l t h p r o f e s s i o n a l s , e s p e c i a l l y in d e v e l o p i n g c o u n t r i e s w h e r e m e d i c a l p s y c h o l o g i c a l e x p e r t i s e is s c a r c e •

T h e r e p o r t ^ of the W H O E x p e r t C o m m i t t e e on the O r g a n i z a t i o n of M e n t a l H e a l t h S e r v i c e s in D e v e l o p i n g C o u n t r i e s ( 1 9 7 4 ) c o n c e n t r a t e d on the p r o v i s i o n of p s y c h i a t r i c s e r v i c e s , and e m p h a s i z e d that these should n o t b e c e n t r a l i z e d or v e r t i c a l l y o r g a n i z e d , b u t that the c a r e of the m e n t a l l y ill should take p l a c e as m u c h as p o s s i b l e w i t h i n the c o m m u n i t y and w i t h i n the f r a m e w o r k of b a s i c h e a l t h s e r v i c e s . This r e p o r t , h o w e v e r , did n o t r e f l e c t the n e e d for the m e n t a l h e a l t h s e r v i c e s to focus on the p r o m o t i o n of m e n t a l h e a l t h and the p s y c h o l o g i c a l d i m e n s i o n of w o r k t h r o u g h o u t the h e a l t h s e c t o r .

O v e r the e n s u i n g y e a r s , m a n y c e n t r e s in the d e v e l o p i n g w o r l d b e g a n to take m e n t a l h e a l t h c a r e into the c o m m u n i t y , some following p a t h s w h i c h h a d b e e n r e c o m m e n d e d by the W H O E x p e r t C o m m i t t e e , and o t h e r s f o l l o w i n g y e t o t h e r i n n o v a t i v e r o u t e s . W H O i n i t i a t e d the C o l l a b o r a t i v e S t u d y on S t r a t e g i e s for E x t e n d i n g M e n t a l H e a l t h C a r e as a f u r t h e r c o n t r i b u t i o n to t h e s e d e v e l o p m e n t s .

5.2 T h e r e p o r t

T h e Study G r o u p r e c e i v e d d e s c r i p t i o n s of i n n o v a t i v e a c t i v i t i e s from m a n y p a r t s of the d e v e l o p i n g w o r l d and the r e p o r t c o n t a i n s e x a m p l e s w h i c h a r e r e p r e s e n t a t i v e of w h a t h a s b e e n h a p p e n i n g over the last 10 y e a r s in some of t h e s e c o u n t r i e s . In a d d i t i o n , a r e p o r t of the w o r k d o n e in the C o l l a b o r a t i v e Study on S t r a t e g i e s for E x t e n d i n g M e n t a l H e a l t h C a r e is

i n c l u d e d as an a n n e x to the r e p o r t .

T h e r e c o m m e n d a t i o n s m a d e by the E x p e r t C o m m i t t e e in 1974 w e r e b o l d and i m a g i n a t i v e , b u t there was no e v i d e n c e that they w e r e feasible in d e v e l o p i n g c o u n t r i e s • D e s c r i p t i o n s of success ful p r o j e c t s w h i c h h a v e b e e n c a r r i e d out over r e c e n t y e a r s w e r e p r e s e n t e d to t h e S t u d y Group； they d e m o n s t r a t e d the f e a s i b i l i t y of the E x p e r t C o m m i t t e e1 s r e c o m m e n d a t i o n s and p r o v i d e d e n c o u r a g e m e n t to take into a c c o u n t the r e s u l t s of t h e s e p r o j e c t s in n a t i o n a l h e a l t h p r o g r a m m e s . T h e G r o u p c o n f i r m e d that d e c e n t r a l i z a t i o n of p s y c h i a t r i c c a r e is a v i t a l a s p e c t in the d e v e l o p m e n t of m e n t a l h e a l t h s e r v i c e s , and that the i n v o l v e m e n t of g e n e r a l h e a l t h c a r e w o r k e r s in m e n t a l h e a l t h c a r e is e s s e n t i a l • It c o u l d see l i t t l e to r e c o m m e n d the b u i l d i n g of any n e w s p e c i a l i s t p s y c h i a t r i c h o s p i t a l s . For the a c u t e l y m e n t a l l y ill the u s e of some b e d s

1 W H O T e c h n i c a l R e p o r t S e r i e s , N o . 6 9 8 , 1 9 8 4 . 2 W H O T e c h n i c a l R e p o r t S e r i e s , N o . 5 6 4 , 1 9 7 5 .

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within or attached to a general hospital is possible. Where specialized facilities are required for the mentally ill, either acute or chronic, these need not be in the form of conventional hospital or psychiatric b e d s , but can be provided within a more informal

s e t t i n g , possibly even outside the health sector, although an input from the health sector is necessary• The role of the mental health professional in treatment, in most instances, would be one of providing supervision, training and consultation rather than direct patient c a r e .

The report deals not only with the provision of treatment for mental disorders, but also with the promotion of m e n t a l health in a broader sense. The role of the mental health

professional in the promotion of mental health should include sensitizing the general health worker to the psychological and social issues affecting their patients. Several of the projects described in the report indicate h o w the promotion of health in general terms has been enhanced by a m e n t a l health contribution. Examples are also given in the report of how the skills of the mental health professionals can also be used in helping those working in other s e c t o r s , particularly those related to coramunity development. Low community morale can lead to a general depression and feeling of helplessness within a community. Behavioural science and m e n t a l health skills have been used to enhance the psychological resources within individuals and release the human potential which can otherwise be subdued in the struggle against h a r d s h i p . In this w a y , community development has been enhanced and made possible•

The report acknowledges that the success of effective mental health programmes often depends upon exceptional leadership, but ineffective programmes can also continue because of the enthusiasm of a key p e r s o n . A l l too frequently the evaluation of an innovative programme h a s not been carried o u t . At the least, h o w e v e r , evaluation should take the form of a

careful definition of the existing services and of those proposed, and a description of the innovative work carried out• A n assessment should always be m a d e of the extent to which a pilot project can indeed be carried into a national health programme.

5.3 The recommendations

The report stresses that every country should formulate a mental health policy and programme as part of its national health programme. There is now no doubt as to the

magnitude of the problem of mental illness in developing countries. If this problem is to be t a c k l e d , it can only be done through work at community level within primary health c a r e , with the provision of supervision and training by mental health professionals and referral

services for the more difficult type of c a r e . The report recommends that governments make provision for a reorganized mental health service so that it can contribute more effectively to all aspects of health c a r e . The supervision and training provided by such professionals will also enable primary health workers to be sensitized to psychological and social problems in general and should provide them with psychological skills which can be used in

strengthening all aspects of health care and also support other sectors which can be involved in the promotion of mental health (e.g., education).

5.4 Significance for public health and implications for the O r g a n i z a t i o n1s programme M e n t a l illness is a major health problem in all countries. Because of the disruption caused by some mentally ill patients, there is often social pressure upon a health service to take action, usually to remove the patient to secure surroundings. Acceding to this demand uses up valuable health resources, is usually not in the best therapeutic interests of the p a t i e n t , and is probably detrimental to the community - which should rather be encouraged to deal with its disruptive members and take care of its disabled at the local level.

The examples presented in this report demonstrate the feasibility of providing a community-based mental health service for the treatment of mental disorders in developing countries•

The promotion of mental h e a l t h , however, involves something more than the treatment of mental i l l n e s s . M o r e o v e r , psychological disorder can occur in the absence of any physical disorder and m u s t be a legitimate concern of the health sector. The report illustrates the wide diversity of m e n t a l health services that have been made available, including examples in which the promotion of mental health was the paramount objective. The Study Group recognized that psychological and social well-being does not automatically follow upon the achievement of physical h e a l t h , and indeed can be achieved in the presence of physical disease. "Health for all" therefore requires specific attention to the psychological and social dimensions of h e a l t h .

Ç B 7 4 / 2 p a g e 11 T h e r e p o r t c o n f i r m s that there is an u r g e n t need for r e s o u r c e s to b e d i r e c t e d n o t o n l y to the t r e a t m e n t of the m e n t a l l y i l l , but a l s o to the e n h a n c e m e n t of the p s y c h o l o g i c a l and s o c i a l d i m e n s i o n s of all a s p e c t s of h e a l t h c a r e . T h e p r o m o t i o n of p s y c h o l o g i c a l w e l l - b e i n g is a l e g i t i m a t e f u n c t i o n of the h e a l t h s e c t o r , p a r t i c u l a r l y t h r o u g h the m o b i l i z a t i o n of c o m m u n i t y a c t i o n .

W H O is r e a d y to c o l l a b o r a t e w i t h M e m b e r S t a t e s in the f o r m u l a t i o n of m e n t a l h e a l t h p o l i c i e s and p r o g r a m m e s . T h e O r g a n i z a t i o n1s p r o g r a m m e i n c l u d e s a c t i v i t i e s a i m e d at e n h a n c i n g the s e n s i t i v i t y of h e a l t h w o r k e r s to the p s y c h o l o g i c a l and s o c i a l a s p e c t s of h e a l t h c a r e . T h e r e p o r t i n d i c a t e s the steps r e q u i r e d to e n s u r e that the p r o m o t i o n of m e n t a l h e a l t h b e c o m e s an e f f e c t i v e as w e l l as e s s e n t i a l e l e m e n t of p r i m a r y h e a l t h c a r e .