I N D E X E D
An addendum to document E B 5 7 / 4 , c o n t a i n i n g the D i r e c t o r - G e n e r a lfs report on f u r t h e r Study Group m e e t i n g s , for w h i c h the reports w i l l be ready i n p r i n t i n E n g l i s h and French by the end of November, w i l l be despatched to Members of the E x e c u t i v e Board a t the b e g i n n i n g o f December.
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTÉ
EB57/4
6 November 1 9 7 5
EXECUTIVE BOARD
Fifty-seventh S e s s i o n
P r o v i s i o n a l agenda item 5
STUDY GROUP REPORTS
Report of the Director-General
INTRODUCTION
I n conformity w i t h r e s o l u t i o n E B 1 7 , R 1 3 , ^ o p e r a t i v e paragraph 4 , the Director-General presents hereunder two study group meetings, for which the reports have now become a v a i l a b l e in E n g l i s h and French.
1 . EARLY DETECTION OF HEALTH IMPAIRMENT IN OCCUPATIONAL EXPOSURE TO HEALTH HAZARDS Report of a WHO Study Group
Geneva, 10-16 December 1974^
1 • 1 Background information
One of the fundamental aims of preventive medicine is to detect m a n i f e s t a t i o n s of d i s e a s e at the stage when physiopathological a n d / o r f u n c t i o n a l changes a r e s t i l l r e v e r s i b l e . Occupational medicine o f f e r s a good example of preventive medicine in that it involves the p e r i o d i c medical examination of workers in the l i g h t of the working and other environmental hazards to which they are exposed. A substantial amount o f information is a v a i l a b l e on b i o l o g i c a l changes that are forerunners of the e a r l y stages of h e a l t h impairment in human exposure to h e a l t h h a z a r d s . This information has not been systematically reviewed or evaluated w i t h a view to preparing p r a c t i c a l g u i d e l i n e s and i n d i c a t i n g gaps in knowledge where research is r e q u i r e d . I n 1973 the WHO Expert Committee on Environmental and H e a l t h Monitoring in Occupational H e a l t h recommended, inter alia， that a long-term programme on
the early detection of h e a l t h impairment i n occupational exposure to h e a l t h hazards should be developed and that d e t a i l e d g u i d e l i n e s should be produced for the comprehensive monitoring of workers 1 h e a l t h to meet needs and resources i n developing c o u n t r i e s . The E x e c u t i v e Board in r e s o l u t i o n E B 5 3 . R 2 3 requested the Director-General to implement these recommendations.
The present Study Group is a f i r s t step towards the development of this long-term programme.
The information provided by the WHO research programme in occupational h e a l t h ,
p a r t i c u l a r l y w i t h respect to the h e a l t h e f f e c t s of exposure to combined hazardous conditions at work, the early m a n i f e s t a t i o n s of occupational r e s p i r a t o r y d i s e a s e s , and methodologies for health monitoring i n developing c o u n t r i e s , was taken into c o n s i d e r a t i o n by the Study Group.
1 , 2 The report
The Group considered c e r t a i n c r i t e r i a i n d i c a t i v e of the s t a t e of h e a l t h and o f e a r l y h e a l t h impairment, ranging from early biochemical and morphological changes r e s u l t i n g from s p e c i f i c occupational exposure to non-specific " i n t e g r a t i v e changes" a s s o c i a t e d w i t h exposures a t work and o u t s i d e work. Many changes can be evaluated q u a n t i t a t i v e l y .
Handbook of Resolutions and D e c i s i o n s , V o l . I， 1948-1972, pp. 14-15.
2 — Wld Hlth Org. techn. Rep. Ser., No. 571.
A detailed account is given of the principles of health evaluation programmes, i . e . the systematic examination of the working population i t s e l f in order to prevent health impairment. Health evaluation and environmental evaluation are not mutually exclusive but complementary.
The Group recognized the wide variation of individual and group reaction to different s t r e s s e s , and examined the endogenous and exogenous factors leading to the increased s u s c e p t i b i l i t y of workers. The report singles out the health effects of exposure to multiple stresses as an area requiring more research.
The use of epidemiological methods in occupational health evaluation was discussed, together with some aspects of the design of studies to evaluate the relationship between exposures and the resulting effects or responses. The Group reviewed the v a l i d i t y of tests to be applied in cross-sectional and longitudinal studies as well as c r i t e r i a for the selection of tests that are both reasonably accurate and f e a s i b l e . Particular attention was paid to simple and practical techniques that do not require sophisticated equipment.
The report refers to the growing importance of psychosocial factors at work and their health implications, both in developing and industrialized countries. I t also points to areas where more knowledge is required, including permissible limits of exposure, the comparability of data, host factors influencing the effects of work factors, evaluation of the effects of combined stresses, the long-term effects of low levels of exposure, and c r i t e r i a for systematic biological monitoring. Several i l l u s t r a t i v e examples are given of the early detection of health impairment, one approach involving the study of physiological function, organ systems and biochemical parameters, the other the study of early health changes in exposure to such chemical agents as carbon d i s u l f i d e and lead and such physical stress as n o i s e .
1 • 3 The recommendations
The Group recommended a long-term programme by WHO aimed at establishing guidelines for the early detection of health impairment, improving the collection and dissemination of information, stimulating research, providing appropriate training, and fostering coordination and cooperation. Governments were asked to institute measures to promote the application of knowledge and set up programmes for the early detection of health impair- ment in workers, encourage the establishment of occupational health i n s t i t u t e s , and introduce appropriate l e g i s l a t i o n .
Comments : The Group succeeded in making significant progress in dealing with the fundamentals of the subject and provided guidelines of practical value. One of the problems that remain to be dealt with is the effect of physical and chemical exposures at relatively low levels that may lead to health impairment in developing countries on account of pre-existing nutritional and other d i s e a s e s . This is an important area of investigation as it may influence decisions on the time and type of preventive health intervention and probably also lead to the discovery of different types of indicators of overall health impairment. The Group established certain criteria for p r i o r i t i e s in future reviews and research areas; they w i l l call for a good deal of study of
occupational health problems in different parts of the world, where limited information is at present a v a i l a b l e . For some time to come, the long-term programme must rely on empirical judgement.
The Group made very l i t t l e reference to the role of health assistants and paramedical personnel in detecting early manifestations of d i s e a s e . By the use of such personnel in developing countries it is possible to detect specific hazardous exposure, predict the effects and watch for early manifestations, at which stage both occupational hygiene and health interventions can be e f f e c t i v e l y introduced. The problem of small industries remains outstanding; as other health programmes and socioeconomic programmes in small industries, the services needed are often not a v a i l a b l e .
EB57/4 page 3
1 . 4 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 n1 s programme
The report is the beginning of the long-term programme recommended in r e s o l u t i o n E B 5 3 . R 2 3 . Research in this f i e l d was a l s o recommended by the Advisory Committee on Medical Research in June 1 9 7 5 . Systematic reviews and g u i d e l i n e s on the e a r l y d e t e c t i o n of h e a l t h impairment have been planned i n accordance w i t h the proposed programme, which is s u b j e c t to adjustment as more information on important occupational h e a l t h problems become a v a i l a b l e through the newly developed occupational h e a l t h information system. These reviews and g u i d e l i n e s a r e
scheduled a n n u a l l y . I n a d d i t i o n , i t w i l l be e s s e n t i a l to i n v e s t i g a t e such areas as the aggravation of general i l l health by occupational exposures and to r e v i s e known p e r m i s s i b l e l i m i t s . B i o l o g i c a l monitoring can be c a r r i e d out in s e l e c t e d occupational groups, making use of c o l l a b o r a t i n g i n s t i t u t i o n s . This would s u b s t a n t i a t e the v a l i d i t y of b i o l o g i c a l monitoring in evaluating the overall exposures of workers and provide new information on e a r l y b i o l o g i c a l changes i n human b e i n g s . WHO should a s s i s t i n developing s i m p l i f i e d r e l i a b l e methods of assessment and control of occupational health problems as these are i n great demand everywhere, p a r t i c u l a r l y i n i n d u s t r i a l i z i n g c o u n t r i e s .
2 . REVIEW OF THE WHO PROGRAMME IN EDUCATIONAL TECHNOLOGY AND COMMUNICATIONS Report of a Study Group
Geneva, 18-25 March 1975 2 . 1 Background information
The WHO programme i n educational technology and communications is a r e l a t i v e l y new o n e , dating back to 1 9 7 1 • S i n c e then, the a c t i v i t i e s i n t h i s f i e l d have been c o n s o l i d a t e d to form a long-term programme of work based on i d e n t i f i e d needs and problems at country l e v e l • Before committing the O r g a n i z a t i o n to such a programme, it was considered opportune to convene a Study Group to review past a c t i v i t i e s and to make a c r i t i c a l study of the long-term p l a n n i n g . I n making i t s recommendations for future a c t i o n , the Group was asked to consider WHO1 s
a c t i v i t i e s in educational technology and communications w i t h i n the context of the
O r g a n i z a t i o n ' s overall programme in h e a l t h manpower development. This is because e d u c a t i o n a l technology is a supporting s e r v i c e and as such cannot be viewed i n i s o l a t i o n from the many programmes to which it can c o n t r i b u t e .
2 . 2 The report
The Group f i r s t reviewed the current status o f educational technology and communications in the work of WHO. I t then studied the O r g a n i z a t i o n1 s o v e r a l l p o l i c y i n the h e a l t h f i e l d , and e s p e c i a l l y new trends and perspectives i n the development of the b a s i c h e a l t h s c i e n c e s and of h e a l t h manpower. This enabled the Group to assess not only the c o n t r i b u t i o n so far made by the programme of educational technology but a l s o i t s relevance to the o v e r a l l programme of the O r g a n i z a t i o n .
The Group described the e v o l u t i o n of educational technology over the past few years and stressed that its main contribution l i e s in the a p p l i c a t i o n of a systems approach to
educational problems that takes into account the overall goals of the i n s t i t u t i o n or programme for which the solution is sought. Educational technologists can a s s i s t the work of WHO i n three main areas :
( a ) i n the diagnosis of an educational problem w i t h i n i t s local context and the development of an educational system which can provide the remedy;
( b ) in a s s i s t i n g teachers to s e l e c t from the wide range o f methods a v a i l a b l e the most appropriate method for student l e a r n i n g i n any given s i t u a t i o n ; and ( c ) i n research i n t o , and the development of new approaches to learning that can function e f f e c t i v e l y w i t h i n the many c o n s t r a i n t s of e d u c a t i o n a l programmes in developing c o u n t r i e s .
1
Document WHO/EDUC/75.176.
I n view of the increasing demand for assistance in educational technology, and to a s s i s t WHO in establishing p r i o r i t i e s , guidelines were proposed for the selection of a c t i v i t i e s that merit the O r g a n i z a t i o n ' s support. The resources required i f WHO were to f u l f i l i t s role in this f i e l d were also considered in the report.
2 . 3 The recommendations
The principal recommendations of the Group were as follows :
( a ) Educational technology can only be exploited fully i f its approaches can be brought to bear from the inception of a programme or project. Consultation should therefore be invoked at the planning as well as the implementation and evaluation stages of a programme or p r o j e c t .
(b) Whenever p o s s i b l e , research and development should be undertaken in relation to the educational technology components of WHO programmes and p r o j e c t s .
( c ) The i n s t i t u t i o n a l i z a t i o n of educational technology as a separate entity should be avoided. Educational technology should be widely employed by WHO as a f a c i l i t a t o r of communication.
(d) The existing network of WHO collaborating centres in various subjects should be expanded to include designated centres of educational technology so that WHO can ensure the maximum impact of the growing contribution of educational technology in Member countries.
( e ) Due attention should be paid to the adequate funding of WHOf s overall a c t i v i t i e s in educational technology, especially in relation to health manpower development.
I t was also recommended that a l l WHO s t a f f should be kept informed of new developments in educational technology that could be of assistance to them in their work, and that the current collaboration with other agencies should be strengthened.
2 . 4 Implications for the O r g a n i z a t i o n ' s programme
The convening of the Group was timely and its deliberations were of value in
formulating the health manpower development component of The Sixth General Programme of Work.
As i t s recommendations were directed towards the Organization and its future a c t i v i t i e s in the f i e l d of educational technology and communications, the report was issued as a document (WHO/ E D U C / 7 5 . 1 7 6 ) rather than in the Technical Report S e r i e s . The report w i l l be of value in a s s i s t i n g the Organization to establish p r i o r i t i e s for future action.
Comments : The recommendation of the Group quoted in paragraph 2 . 3 ( d ) above needs to be broadened to conform to the current health manpower development policy, which is to encourage the creation of multidisciplinary educational resource centres that can provide a wider service to countries and institutions than educational technology alone.
_
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTÉ
E B 5 7 / 4 A d d . 1 5 December 1 9 7 5EXECUTIVE BOARD
Fifty-seventh Session P r o v i s i o n a l agenda item 5
STUDY GROUP MEETINGS
Report of the Director-General
1 1
m
INTRODUCTION
This document is an addendum to the D i r e c t o r - G e n e r a l ' s report on two study group
m e e t i n g s , issued on 6 November 1975 as document E B 5 7 / 4 , Two a d d i t i o n a l study group meetings are reviewed h e r e , the reports of which have become a v a i l a b l e in the meantime i n E n g l i s h and F r e n c h .L
those of
3 .
4 .
The sequential numbering of the two reports i n t h i s addendum i s consecutive to the reports reviewed i n document E B 5 7 / 4 , namely:
HEALTH HAZARDS FROM NEW ENVIRONMENTAL POLLUTANTS Report of a WHO Study Group
STATISTICAL INDICES OF FAMILY HEALTH Report of a WHO Study Group
THE REVIEW
3 . HEALTH HAZARDS FROM NEW ENVIRONMENTAL POLLUTANTS Report of a WHO Study Group
Geneva, 30 September - 5 October 1974^
3 . 1 Background information
The WHO meeting on environmental health c r i t e r i a , h e l d i n November 1 9 7 2 , discussed the scope o f the WHO programme on the assessment of the e f f e c t s on health of environmental • h a z a r d s , and pointed out the need for early i d e n t i f i c a t i o n of the p o t e n t i a l h e a l t h hazards of new chemicals and other products introduced into the environment. The subject was again b r i e f l y reviewed by a WHO S c i e n t i f i c Group on Environmental Health C r i t e r i a , i n A p r i l 1 9 7 3 , which recommended that an e f f o r t should be made to develop health c r i t e r i a for environmental hazards i n p a r a l l e l with the introduction of new chemical, physical and b i o l o g i c a l factors i n i n d u s t r y , the community and the environment. The Twenty-sixth World Health Assembly in r e s o l u t i o n W H A 2 6 , 5 8 ^ requested the Director-General to accord high p r i o r i t y to the early i d e n t i f i c a t i o n of environmental health hazards and the prévention of t h e i r e f f e c t s , and to study and develop a coordinated programme for the assessment of the e f f e c t s on man of b i o l o g i c a l , chemical and p h y s i c a l agents i n the environment, i n c l u d i n g new and p o t e n t i a l l y hazardous substances. I n response to these recommendations and r e q u e s t s ,
on Health Hazards from New Environmental P o l l u t a n t s was convened to assess of f o r e c a s t i n g health hazards from new environmental p o l l u t a n t s , to review problems, and to provide guidance on the i n i t i a t i o n of national programmes
the Study Group e x i s t i n g methods some p r i o r i t y i n this f i e l d .
Attached (for members of the Executive Board o n l y ) , Document С Е Р / 7 5 . 4 .
Handbook of Resolutions and Decisions， V o l , I I， 1973-1974， pp. 18-19.
3 . 2 The report
The Study G r o u p ' s report consists of three main p a r t s : forecasting i n environmental h e a l t h , methods of i d e n t i f y i n g new or p o t e n t i a l environmental pollutants and h a z a r d s , and a review o f some topics that should be given p r i o r i t y a t t e n t i o n .
The goals of technological forecasting as applied to environmental health are the systematic i d e n t i f i c a t i o n , a n a l y s i s and evaluation of the p o t e n t i a l e f f e c t s of technological developments on human h e a l t h . Such forecasting must also assess and i d e n t i f y means of
preventing new environmental h e a l t h hazards• In discussing p o s s i b l e methods for forecasting new environmental h e a l t h problems, the Study Group reviewed the r e g i s t r a t i o n of new chemicals，
the r e l a t i o n s h i p between chemical structure and b i o l o g i c a l a c t i v i t y , the assessment of the behaviour of chemicals i n the environment, and the a p p l i c a t i o n of rapid laboratory bioassay systems for testing the m u t a g e n i c i t y , carcinogenicity and teratogenicity of chemicals and for screening for ecological e f f e c t s .
The second part of the report i s concerned with methods of i d e n t i f y i n g new or p o t e n t i a l environmental pollutants and h a z a r d s . Particular a t t e n t i o n was given to the evaluation of the p o s s i b i l i t y of setting up t o x i c o l o g i c a l data b a n k s , and of developing warning systems for adverse h e a l t h e f f e c t s that may include use o f health s t a t i s t i c s , a p p l i c a t i o n of experience obtained i n occupational h e a l t h , s p e c i a l environmental surveys of chemicals, ecological s u r v e i l l a n c e , and epidemiological s u r v e i l l a n c e .
The last part o f the report contains examples of topics which should be given p r i o r i t y i n programmes for the i d e n t i f i c a t i o n of health hazards from new environmental p o l l u t a n t s . The f i r s t topic included was consideration of the impact on environmental health of power production and u s e . The Group pointed out that energy was a p u b l i c concern, not only because i t i s e s s e n t i a l for human a c t i v i t i e s , health and even l i f e i t s e l f , but also because o f i t s s i g n i f i c a n c e for the environment. I n order to ensure that the complete range of p o s s i b l e energy-related h e a l t h problems i s considered, the Study Group prepared a l i s t of a l t e r n a t i v e energy sources, t h e i r impact on the environment, the related health h a z a r d s , and the p o s s i b l e action that WHO could take i n this area. The second topic reviewed was the technology of chemicals and m a t e r i a l s , another f i e l d where rapid development has taken place during the last d e c a d e s . Among the problems requiring a t t e n t i o n the Study Group pointed out the industry of p l a s t i c s and p l a s t i c i z e r s , the use of f i r e r e t a r d a n t s , the u t i l i z a t i o n of new m e t a l s , the use of p h o t o s e n s i t i z e r s , and the new developments i n chemical pest control.
The report contains seven annexes, which provide more d e t a i l e d technical information on t o x i c o l o g i c a l data banks and on h e a l t h and environmental hazards related to power production and the technology of chemicals and m a t e r i a l s .
3 . 3 The recommendations
The Study Group made f i f t e e n recommendations among which a t t e n t i o n is drawn to the
f o l l o w i n g : ' ( a ) Member States should e s t a b l i s h systems for evaluating new chemicals that are introduced
into commerce a n d , when a p p r o p r i a t e , for regulating their u s e ;
( b ) WHO should develop d e t a i l e d g u i d e l i n e s concerning the type of information that i s needed to assess the p o s s i b l e h e a l t h r i s k associated w i t h new chemicals and w i t h new uses of e x i s t i n g chemicals ;
( c ) WHO and other appropriate i n t e r n a t i o n a l organizations should provide technical a s s i s t a n c e to help strengthen environmental health forecasting c a p a b i l i t i e s in developing countries ；
EB57/4 Add.l page 3
(d) Member States should e s t a b l i s h , strengthen and consolidate t o x i c o l o g i c a l data b a n k s , g i v i n g p a r t i c u l a r a t t e n t i o n to the ready a c c e s s i b i l i t y of such data banks to the i n t e r n a t i o n a l s c i e n t i f i c community；
( e ) Member States should give h i g h p r i o r i t y to improving their health s t a t i s t i c s ; and WHO should suggest ways of i n c r e a s i n g the u s e f u l n e s s of n a t i o n a l r e g i s t r i e s ( e . g . cancer
r e g i s t r i e s ) and should encourage t h e i r standardization；
( f ) WHO, i n cooperation w i t h other i n t e r e s t e d o r g a n i z a t i o n s , should encourage comparative c o s t / r i s k / b e n e f i t studies of the consequences for h e a l t h of the use of conventional sources of nuclear energy;
( g ) A greater proportion of n a t i o n a l and i n t e r n a t i o n a l research on environmental p o l l u t i o n should be d i r e c t e d towards the i d e n t i f i c a t i o n and assessment of new chemical problems that are l i k e l y to a r i s e i n the future.
3 , 4 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 n1 s programme
The report provides guidance for future WHO a c t i v i t i e s r e l a t e d to the prevention of health hazards from environmental p o l l u t a n t s and other hazards. WHO has already an a c t i v e programme which consists of preparing preliminary reviews of chemicals that are l i k e l y to be i n c r e a s i n g l y used i n industry and as chemical consumer products. I n this programme, which i s being conducted w i t h the support of the United Nations Environment Programme ( U N E P ) ,
p a r t i c u l a r a t t e n t i o n i s given to the d e t a i l e d e v a l u a t i o n of the future uses a f such chemicals, i n c l u d i n g the volume of t h e i r production and the e v a l u a t i o n of e x i s t i n g t o x i c o l o g i c a l
information. Such reviews also provide guidance on the biomedical research needed to improve our knowledge of the toxic a c t i o n of chemicals. Another approach to this problem that was d i s c u s s e d by the Study Group i s the systematic review of s p e c i f i c i n d u s t r i e s i n order to evaluate the h e a l t h problems, p a r t i c u l a r l y i n view of the future development of the technolo- g i e s used i n those i n d u s t r i e s . A d i r e c t outcome of the Study Group 1 s recommendations i s a symposium on environmental h e a l t h hazards from p l a s t i c s and the synthetic rubber i n d u s t r i e s , to be held i n February 1976 and co-sponsored by WHO and the National I n s t i t u t e on Environmental Health Sciences (NIEHS) at Research Triangle P a r k , North C a r o l i n a . NIEHS i s one of s i x new WHO c o l l a b o r a t i n g centres on environmental health e f f e c t s . The cost of the symposium w i l l
be largely covered by the NIEHS. As regards the t o x i c o l o g i c a l data banks WHO, together w i t h UNEP, is a c t i v e l y considering the strengthening of s c i e n t i f i c c o l l a b o r a t i o n on a l l h e a l t h aspects o f the planned i n t e r n a t i o n a l r e g i s t e r of p o t e n t i a l l y toxic chemicals, a UNEP p r i o r i t y p r o j e c t .
Another topic on which the Study Group 1 s recommendations provide u s e f u l guidance i s the WHO a c t i v i t y concerning h e a l t h hazards of a l t e r n a t i v e power production systems. Contacts have been e s t a b l i s h e d w i t h the I n t e r n a t i o n a l I n s t i t u t e of A p p l i e d Systems A n a l y s i s ( I I A S A ) i n view of WHO p a r t i c i p a t i o n i n the IIASA energy p r o j e c t , w i t h s p e c i a l reference to the
e v a l u a t i o n of health hazards r e l a t e d to power production and the methodology for s e t t i n g up environmental quality standards.
Comments: The recommendations of the Study Group are of d i r e c t relevance t o , and provide d e t a i l e d suggestions f o r , the i n t e n s i f i c a t i o n of WHOfs programme i n this f i e l d . The topics d i s c u s s e d i n the Study Group 1 s report represent a new approach for the WHO environmental h e a l t h programme, p a r t i c u l a r l y as regards the preventive aspects of environmental control a c t i o n . The d i s t r i b u t i o n of e x p e r t i s e among the Study Group members was a d e q u a t e , w i t h the p o s s i b l e exception of e x p e r t i s e on the h e a l t h hazards from power production. Although this part of the report i s rather s h o r t , i t nevertheless gives a very u s e f u l l i s t of p r i o r i t y topics which should be considered i n r e l a t i o n to a l t e r n a t i v e power conversion systems i n the f u t u r e . The coverage of the report may be considered too w i d e , and i n some places too t e c h n i c a l , but this was necessary at the present stage of the development of the WHO programme
i n t h i s a r e a . The s e c r e t a r i a t considers this report a very useful and v a l u a b l e document, which provides d e t a i l e d guidance for WHO'S programme.
4 . STATISTICAL INDICES OF FAMILY HEALTH Report of a Study Group
Geneva, 17-22 March 1 9 7 51
4 . 1 Background information
I n s p i t e of i t s u n i v e r s a l l y central r o l e i n s o c i e t y , the family has been i n f r e q u e n t l y s t u d i e d from the community health point of v i e w .
The i n t e r r e l a t i o n between h e a l t h and the family i s not a s t a t i c phenomenon but a dynamic process. The concept of the life-cycle of the family c o n s t i t u t e s an important frame of r e f e r e n c e , permitting the h i s t o r y of a family to be traced through i t s various stages of development. I t i s thus a u s e f u l tool for studying v a r i a t i o n s i n social and economic behaviour and r e l a t i n g them to the health experience o f the family and i t s members.
I n 1971 WHO convened a Consultation on the S t a t i s t i c a l Aspects of the Family as a Unit i n H e a l t h S t u d i e s , i n Geneva, to advise WHO on how to review the various approaches to the study o f family h e a l t h i n order to obtain g u i d e l i n e s for the t r a n s l a t i o n of the concept of family h e a l t h into an o p e r a t i o n a l tool s u i t a b l e for the c o l l e c t i o n and a n a l y s i s of relevant data y and to discuss p o s s i b l e sources of information for the study of health and d i s e a s e , w i t h p a r t i c u l a r emphasis on the p o s s i b i l i t i e s of better u t i l i z a t i o n of already e x i s t i n g information.
The report of t h i s Consultation was used as a b a s i s for a Consultation on Family H e a l t h , h e l d i n 1972 i n Geneva, At the same time, i t served as a u s e f u l point of departure and reference for the development of an i n t e r d i s c i p l i n a r y programme i n the area of family health s t a t i s t i c s , and a l s o helped i n preparing for the Study Group on S t a t i s t i c a l I n d i c e s of Family H e a l t h , which was convened w i t h the following o b j e c t i v e s :
( a ) to survey recent developments and current a c t i v i t i e s i n the measurement of family
( b ) to i d e n t i f y and evaluate various approaches and i n d i c e s of family h e a l t h ; ( c ) to consider v a r i o u s components of a family health data b a n k ;
( d ) to provide help i n e s t a b l i s h i n g a l i s t of p o s s i b l e p r i o r i t i e s for research；
( e ) to provide recommendations for future a c t i o n . 4 . 2 The report
The main focus of the Study Group was the i d e n t i f i c a t i o n of i n d i c e s of family health
" s t a t e s " s u i t a b l e for s t a t i s t i c a l use i n measuring family h e a l t h . Since the area of c o n s i d e r a t i o n under the general framework of family health i n d i c a t o r s i s broad and at best i l l - d e f i n e d , the i n t e r d i s c i p l i n a r y implications tend to be considerable and the problems of measurement complex. There was agreement that the search for i n d i c e s ought to be directed
towards the i d e n t i f i c a t i o n of factual o b j e c t i v e measurements which are reproducible or of v a r i a b l e s which i n d i r e c t l y measure the phenomena. Such i n d i c e s must not only be capable of measuring the family health " s t a t e " of one family i n time and place but be u s e f u l for the a n a l y s i s of the " h e a l t h s t a t e " of aggregrations of f a m i l i e s as w e l l .
Primary emphasis was p l a c e d on: ( a ) demographic i n d i c e s , ( b ) marital health i n d i c e s , ( c ) p h y s i c a l and organic h e a l t h i n d i c e s , ( d ) social i n d i c e s , and ( e ) family planning i n d i c e s of family h e a l t h . A t t e n t i o n was drawn to the t e c h n i c a l , f i n a n c i a l and methodological problems involved i n the c o l l e c t i o n a n a l y s i s and i n t e r p r e t a t i o n of p e r t i n e n t d a t a . New developments, such as the use of health calendars for the c o l l e c t i o n of reasonably accurate i n f o r m a t i o n , were reviewed and were found a promising avenue for the f u t u r e .
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The complexity and volume of the information needed for family health studies make the task of setting up a data bank for this purpose d i f f i c u l t , since i t depends largely on the level and standard of o f f i c i a l s t a t i s t i c s and on their organization and computerization.The merging and linkage of various standardized registers and records into an integrated data bank system exist only in a few countries. Integrated operation with family-oriented
information, including the results of samp le surveys and relevant extracts of family budget surveys, i s practically non-existent. Since the development of a computerized population register i t s e l f is a very long-term and costly process, the prospects of a data bank for
family health are not very promising•
Pointing out the advantages and limitations of s t a t i s t i c a l indicators for the proper understanding of the phenomena studied, the Study Group sought to identify a number of generally agreed upon variables which might serve as possible selected indices of family h e a l t h ; these have been included as an annex to the report. While some of these indicators are f a i r l y well e s t a b l i s h e d , others are s t i l l in a very formative stage and are in need of further exploration. Thus they should be taken as suggesting areas in which s p e c i f i c indices can be constructed rather than as constituting a d e f i n i t i v e expression of endorsement.
4 . 3 The recommendations
The Study Group's major recommendations are:
( a ) WHO should undertake a detailed study of the d e s i r a b i l i t y , f e a s i b i l i t y and limitations of developing an index or series of indices capable of expressing some of the aspects of the health status of a family. This should include consideration of the s t a t i s t i c a l framework as well as development of methods for data collection and appraisal for a coherent family health information system. In this context, the notion of the family as a unit i n health
studies should be further developed. This i s of c r i t i c a l importance in view of i t s relevance not only to health s t a t i s t i c s but to the area of health and family studies in general.
(b) I n order to help promote greater international comparability, WHO should:
( i ) continue to work on standard d e f i n i t i o n s , terminology, c l a s s i f i c a t i o n s and guide- lines for data c o l l e c t i o n , treatment and publication and to promote their acceptance i n Member countries；
( i i ) stimulate, i n i t i a t e and coordinate international comparative studies with a view to investigating in-depth factors impairing international comparability；
( i i i ) develop internationally accepted c r i t e r i a for the quality of family health s t a t i s t i c s ；
( i v ) consider providing assistance to Member States in developing, improving and appraising their national data-base on family health;
(V) call on countries to supply information on operating data bank systems, high- lighting the assessment and evaluation of existing records and registers and their actual and/or possible use for the i d e n t i f i c a t i o n of families.
( c ) WHO should:
( i ) establish one or more reference centres for the assembling and dissemination of source material relating to family health studies - this would include work (published or otherwise) on, for example, methodology and a l l aspects of the family related directly to health;
( i i ) continue and broaden the c o l l e c t i o n , consolidation and analysis of national family health s t a t i s t i c s .
( d ) There is a need for a phased programme of research whose aim must be to develop a set of measures that w i l l help to determine whether or not - and in what pattern - certain family structural and functional characteristics may be related to h e a l t h , i l l n e s s , accident and d i s e a s e . I n so doing, consideration should be given to the development of sensitive measures of family structure, function and interaction that can be used in health studies. As a preliminary step, a compilation and evaluation of measurement techniques currently being used i n a v a r i e t y of countries should be undertaken.
( e ) WHO should encourage the collection of morbidity and family data within national sample surveys in order to obtain necessary information about the relationship between family
characteristics and health.
( f ) I n the evaluation of health services and programmes, including those of family p l a n n i n g , special attention should be paid to their a v a i l a b i l i t y and acceptability to the family as a u n i t , and to their effectiveness in promoting family health.
( g ) WHO should promote the recording of family data on individuals at points of occurrence of v i t a l events and at points where individuals enter the medical care system, when
information for s t a t i s t i c a l purposes i s normally recorded. Such data should include, as a minimum: type of family, characteristics of family head, size of family and, for each member, r e l a t i o n s h i p to family head, marital status and age of family members. To achieve this o b j e c t i v e , cooperation with the United Nations w i l l be e s s e n t i a l .
( h ) WHO should endeavour to arrange that, in the future, census tabulation programmes developed by the United Nations should incorporate tables that provide denominator data for the analysis of v i t a l health records, and also the necessary bench-mark data for studies of family health.
( i ) WHO should cooperate as closely as possible with the United Nations and other interested agencies to f a c i l i t a t e the exchange of results from research on families.
( j ) I n view of the importance that the family life-cycle may have for family health, more a t t e n t i o n should be given to the application of this concept and to a developmental approach i n family health research. To further this aim, a small joint working group composed of members of the United Nations secretariat and WHO should be formed to help accomplish this task.
4 . 4 Implications for the O r g a n i z a t i o n ' s programme
The report provides guidance for future WHO work i n the f i e l d of family health s t a t i s t i c s . I t i d e n t i f i e s certain priority areas for a c t i o n , and underlines the importance of strengthening i n t e r d i s c i p l i n a r y cooperation. I n p a r t i c u l a r , it urges WHO to promote the inclusion of family-related information in population census and v i t a l s t a t i s t i c s programmes, as well as in health surveys and medical records. A joint working party has already been set up with the United Nations to study methodological issues related to the family life-cycle approach in
family health and to work out a joint report on major demographic and health implications of the changing family spectrum. The f i r s t part of a WHO-initiated study on "Health and the family: Studies on the demography of family l i f e cycles and their health implications" has been completed and is being submitted for publication.
Comments: The Study Group covered a wide range of issues related to the statistical measurement of family health. The participation of experts from various d i s c i p l i n e s , and of WHO s t a f f from headquarters and from some of the regional o f f i c e s , underlined the multiple aspects of family health. The review of the present state of a c t i v i t i e s was found extremely u s e f u l , as was the forum which the Study Group provided for an exchange of views and experience. Its i d e n t i f i c a t i o n of major gaps in the availa- b i l i t y , a n d in the appraisal of the quality and relevance of information, and its i n s i s t e n c e not only on developing new measurement tools but also on promoting the imaginative application of e x i s t i n g techniques, such as some standard actuarial methods in the analysis of the demography of family h e a l t h , gives a solid basis for WHO1 s further work in this area.
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