ting out the journal had also taken on the publication of a Spanish edition of the Chronicle of the World Health Organization as well as translations of various technical works. By this time the Boletín had expanded far beyond its initial length of 26 pages QUOTE 5 and was publishing many more articles based on original research. In 1951 it served as the vehicle for a survey on health education and in 1953 a new section was added on the subject. The ideas explored in this section coincided to a large extent with new developments in the search for health which were being discussed at major international congresses. The Boletín gave increasing attention to statistics, environmental health, and the health needs of the elderly, and it began to publish essentially monographic issues devoted almost exclusively to specific subjects, including poliomyelitis, malaria, nursing, and medical education, among others. In 1953, 1955, and 1959 supplements were published that included scientific material from the Institute of Nutrition of Central America and Panama. A forerunner of the current section entitled "Communicación biomédica" was Selma Debakey's article on the preparation of medical articles (October, 1955). When Dr. Abraham Horwitz was elected Director of the Organization, the first Latin American to occupy this position, he became a frequent contributor of incisive articles and editorials. At that time the Boletín was reporting monthly on progress toward the eradication of Aedes aegypti and had begun to publish the first articles on the new topic of economics and health. It was also carrying a growing number of articles on scientific research from Latin American countries, as well as materials from the Bulletin of the World Health Organization. The dynamic events of the famous meeting of Punta del Este in 1961, and PAHO's role in that gathering, led to a new emphasis on health as a component of development, an idea that gained momentum during the administration of Dr. Héctor Acuña and continues to be an important focus under the present Director, Dr. Carlyle Guerra de Macedo. QUOTES 6 and 7 By 1966 it had been recognized that there was a need to publish a greater number of articles in English, and the Bulletin of the Pan American Health Organization was created. Up to 1970 it came out once a year and featured selections from the Boletín. Three issues were published in 1972, and in 1973 the current quarterly publication schedule was adopted. Today the Bulletin is aimed mainly at English-speaking readers in the Caribbean countries and the articles are selected with that criterion in mind, independently of the articles published in the Boletín. In 1972 the Boletín celebrated it 50th anniversary, the occasion being marked with the publication of an historical account in the May issue. With characteristic foresight, during the previous year the Boletín had carried several articles on cholera with a view to preparing the countries of Latin America for the possibility of a seventh pandemic. An article by Albert Sabin on the elimination of poliomyelitis had also been published. In 1973 the Boletín announced the most dramatic news in its history: smallpox had been completely eradicated from the Americas. A few years later, in 1978, it published the monumental Declaration of Alma Ata. Under Dr. Acuña, responsibility for the production of several publications, including the Boletín, was transferred to the PAHO Representation in Mexico, although the journal's technical content continued to be decided by the Office of Health and Biomedical Publications at Headquarters. In 1982, as the result of a cost- benefit study ordered by the current Director, Dr. Guerra de Macedo, the decision was made to return all publication services to Headquarters. In recent decades, the Boletín's focus has shifted away from general information toward more specific priority subjects. A new quarterly section called "Información farmacológica" was inaugurated in July 1980 and today provides ongoing support to the national agencies responsible for drug regulation. With the creation of new specialized journals such as the Boletín Epidemiológico, Educación Médica y Salud, and the Boletín Informativo PAI, as well as the publication of journals by the various PAHO centers, the Boletín has gradually been relieved of responsibility for disseminating the type of information carried by those publications and has been able to turn its attention to bridging information gaps in other areas. While in earlier days articles were reviewed by the technical programs of the Organization through an Advisory Committee, since the 1980s this function has been carried out through a system of peer review, in keeping with the practices of other international biomedical journals. As a result, the quality of the papers selected for publication has steadily improved. Since 1989, a section entitled "Comunicación biomédica" has been offering technical criteria for research and for the preparation of papers while at the same time endeavoring to foster the capacity for critical evaluation among its readers. The section "Libros" reviews more than 100 books a year and "Cartas de los lectores" provides a forum for readers to share their observations. The Boletín has a pressrun of 16,500, is listed in various indexes and electronic data bases, and receives between 350 and 500 articles each year, 15% to 20% of which are eventually published. Lengthy special numbers of the Boletín have examined some of the major concerns of our time, including mental health, economics and health, AIDS, drugs, and bioethics. The dynamic editorials of Dr. Guerra de Macedo are paving new roads for the consolidation of Regional solidarity and the search for health and equity as part of development. Over the past seventy years, the Boletín has kept pace with the unprecedented evolution of knowledge and applications in the health sciences, from the development of new antibiotics and vaccines to the spectacular advances in biotechnology. As a depository and an organ for the communication of knowledge, and through its support for scientific research, the Boletín has made an undeniable contribution to the development of public health in the Western Hemisphere. As the voice of the Organization, it has also guided the Member Governments in the application of collectively approved health policies and activities. Above all, the Boletín has helped to nuture Latin American thinking about public health and cooperation among countries. Its pages will continue to reflect the forward-looking concerns of those who have devoted their lives to the fight against poverty and disease, and the Boletín will continue to chronicle both the milestones reached and the failures and setbacks encountered in the ongoing effort to achieve well-being for the peoples of the Americas. QUOTE 1 In addition to the special articles about the cause, prevention, and control of diseases, the Boletín Panamericano de Sanidad has published monthly detailed data concerning the existence of reportable diseases throughout the world but especially in Latin America. It has also published information on sanitation and the maintenance of public health. This Boletín is sent free of charge to departments of health, practicing physicians, health officials, and other concerned individuals in Latin America. We have received many commendations on the Boletín as well as numerous assurances that it is indeed filling a gap. -- Report of the Director, 1921- 1922 QUOTE 2 It is my ambition and desire to make the Boletín fully worthy of your confidence and deserving of whatever time you may spend reading it. Report of the Director, 1927 QUOTE ON MALARIA Malaria has long been a dreaded enemy in tropical and subtropical regions of the Americas. Not only has it hindered material progress in the countries of these regions but it has also given them a reputation as unhealthful and dangerous places, which is the worst damage it could have done. Anyone who is concerned with preventing this scourge should contact the International Sanitary Bureau. Notice that appeared regularly in the Boletín beginning in December 1922 QUOTE 3 The authors of articles solicited by the Director of the Bureau will receive 20 copies of the Boletín free of charge. Authors who submit papers that are accepted for publication will receive 10 copies of the Boletín free of charge. Reprints may be obtained by the author for a fee, which currently is US$0.50 per page for 100 copies, with a four-page minimum. A surcharge will apply to illustrations that require special paper. Excerpt from the instructions for contributors published in the Boletín, 1949 QUOTE 4 The Boletín has now been engaged in carrying out its mission for 30 years. Its format has evolved as progress has been made in production techniques, although the emphasis has always been more on substance than on form. Conributions by physicians and health specialists from all the countries have found their way onto the pages of the Boletín. This body of thought by the men of the Americas who are concerned with public health is a valuable historical legacy that will continue to shape the future. -- Boletín, May 1952 QUOTE 5 One of the primary functions of the Pan American Sanitary Bureau is to serve as an international center for the collection and dissemination of scientific information and knowledge about public health and related sciences. Boletín, November 1953 QUOTE 6 The Boletín fulfills one of its ineluctable duties by presenting its readers with the most important information culled from the documentation available. --Abraham Horwitz, referring to the meeting of Punta del Este QUOTE 7 "As the number of readers increased, the monthly pressrun [of the Boletín] rose from 11,100 copies in 1966 to more than 14,300 by the end of 1969. In the four-year period some 280 articles were published, from authors in all parts of the Americas as well as other regions of the world, in addition to the sections devoted to medical and health news and reports on other items of interest." --Quadrennial Report of the Director, 1966-1969 PHOTO CAPTIONS Photograph of Dr. Juan Guiteras. The Boletín de la Oficina Sanitaria Panamericana came into being as the result of a proposal made by him at the VI International Sanitary Conference. Commemorative seal of the VI International Sanitary Conference, which was the inspiration for the logo used by the Boletín for a number of years. Delegates to the second Pan American Conference of National Directors of Health, August 1931. Considerable time during this meeting was devoted to discussion of how the Boletín would be distributed to inland cities and populations. OBSERVATIONS ON THE DOCUMENT "THE MASTER PLAN FOR S. PNEUMONIAE PREVALENCE STUDY" 1. The title of the document and the contents of the first paragraph are not consistent with the language used in the proposed protocol, which is aimed at determining the prevalence of the various serotypes of S. pneumoniae in cases of pneumonia in children under five years of age for the purpose of preparing a vaccine. A study of prevalence of S. pneumoniae, as the title and the first paragraph suggest, should include an overall sample of individuals among whom children--and children with pneumonia- -would constitute merely a subgroup to be considered. 2. Analysis of the remainder of the document will be made in consideration of the fact that the objective of the study is expressed in the proposal in the first paragraph of Point 1. 3. A design plan for this objective might include: - A definition of the target population of the study. - An estimate of the size of the sample. - A description of the techniques that will be used. - The duration of the study. - The procedures to be followed in analyzing the results and drawing conclusions. 4. The five points above are included in the document under study. Some general considerations on each are presented below. 5. Definition of the Target Population of the Study: - Number of countries: A hypothesis should be established on the basis of which the number of countries in the Region to be included in the study will be determined. Given that the vaccines in use in other countries (Europe) cannot be used in Latin America, since they act on different serotypes, the possible reasons for these differences should be analyzed in order to determine how many and which countries should be studied. For example: Will it be possible to infer the situation in Nicaragua, Ecuador, and Paraguay from the results obtained in Brazil, Bolivia, and Mexico? Epidemiological aspects may be considered in the selection of the countries, but this does not provide an answer to the above question. - Age groups: Although the population should be stratified by age in order to consider possible variations in the distribution of serotypes, certain special groups (two or three-month old infants) in which pneumonia is especially serious should be taken into account. - Geographical distribution: In order for the population to be representative it should include different geographical areas within the countries. Consideration should be given to whether the distribution of the different serotypes of S. pneumoniae is the same in urban and rural areas in order to include populations in both areas. Consideration of the rural area is important because the rural population accounts for many of the deaths due to pneumonia that take place each year because of lack of access to the health services or because care is provided too late. - Case definition: In accordance with the target of the study (first paragraph, Point 1 of these observations), a clear definition of "case of pneumonia" will be required, and it should be established whether the definition adopted will be verified with a pattern in order to confirm the diagnosis. The criteria proposed by PAHO/WHO are adequate but have been prepared with another objective (to identify the greatest number of possible cases of pneumonia in order to avoid death caused by not receiving adequate treatment). The objective of the study requires that the greatest number of possible cases are really pneumonia, and consequently these criteria should be supplemented with other criteria to increase their specificity. - Other factors: Some of the considerations formulated in the document under study are of great importance. The population that is served by hospitals of high or medium complexity does not appear to be appropriate for obtaining results that lend themselves to extrapolation. Although there are studies that show that a high proportion of the isolated nasopharyngeal serotypes from carriers are the same as those that have been found to produce pneumonia, the role played by carriers in transmitting the disease is not clearly known. The availability of adequate infrastructure in the countries is a very important operational factor for the success of the study. However, if countries or areas within the countries are not included because of these limitations, decisions should be taken in consideration of the observations formulated under "Number of countries" and "Geographical distribution" on this same point. Are the serotypes that cause pneumonia in children the same when they are associated with risk factors such as malnutrition and environmental pollution exist? 6. Estimate of the Sample Size: Estimate of the sample size should be associated with the conclusions that are expected to be drawn and the degree of generality to be given them. To the extent that the groups to be studied are stratified, the size of the sample will increase. On the other hand, failure to stratify the study may make it impossible to make adequate generalizations. Some additional limitations are determined by current lack of knowledge of the values of incidence of S. pneumoniae it is expected to find in each group and the different serotypes it might be possible to find in each. More information should be compiled in this respect. 7. Description of the Techniques To Be Employed: The considerations presented in the document under consideration include the principal concerns that can be expressed in this respect. 8. Duration of the Study: There are no means available to prepare hypotheses on the variability over time of the causative serotypes of pneumonia in children. Consequently, observations cannot be formulated for the period of 18 months proposed. 9. Procedures for Analyzing the Results and Drawing Conclusions: The protocol should include details of these procedures. The drawing of conclusions and their degree of generality should be closely associated with the decisions that are taken with regard to the points referred to above. HPM/DRC, difab.mp UNIVERSAL AVAILABILITY OF ESSENTIAL DRUGS: A HEALTH TARGET IN THE AMERICAS Of all the spectacular advances that have been made during the twentieth century, few have benefited humankind as much as the development of safe and effective drugs. The continuous search for new drugs has given rise to a huge transnational pharmaceutical industry and to thousands of commercial products whose quality, safety, registration, supply, advertising, and use require careful regulation. As a health agency, the Pan American Health Organization (PAHO) has been a leader through the years, playing a fundamental and decisive role in setting regulatory policies in this area. Traditionally, technological dependency has made it necessary for the health sectors in Latin America and the Caribbean to devote a major portion of their budgets to the purchase of pharmaceutical products. At the same time, they have been unable to overcome some of the difficulties characteristic of developing societies: unavailability of drugs to certain groups, lack of information and false claims about drugs, discrepancies between demand and real health needs, inappropriate use of products, and ineffective supply systems. PAHO, seeking to confront these problems and adapt its policies to the priorities of the moment, has provided advisory services to the countries of the Americas on an ongoing basis with a view to placing safe, effective, good-quality pharmaceutical products within the reach of all segments of the population. Early Activities of the Pan American Sanitary Bureau (PASB) The United States Pharmacopeia, first published in 1820 and since updated a number of times, was the officially recognized list of drugs in the United States at the beginning of this century. In 1905, the II International Sanitary Conference proposed that it be translated into Spanish in order to provide a basic reference for physicians and pharmacists in the Americas. The project was slow to come to fruition, but the translation of the Eleventh Revision of the Pharmacopeia and its First Supplement was finally published in 1936. It was followed three years later by the translation of the Epitome of the Second Supplement. This impressive effort, carried out by the Bureau with the assistance of auxiliary commissions from Cuba, Puerto Rico, and the Philippines, is one of the earliest and most outstanding examples of international scientific collaboration. In the early part of the present century all the countries had independent pharmacopeias and there was a pressing need to establish a common standard. As early as 1923, the V International Conference had recommended that the countries adopt uniform regulations, and in 1924 the VII Pan American Sanitary Conference laid the foundation for the corresponding legislation. The proposals of that Conference were subsequently adopted by the IX Pan American Sanitary Conference in 1934, which also designated PASB to act as liaison between the national commissions of the American pharmacopeias. In this connection, in 1938 the Bureau published a series of 24 articles in the Boletín under the title "La Farmacopea y el médico." Expansion of the Pharmaceutical Industry The Bureau's efforts in the area of drug regulation gained momentum with the rapid growth of the pharmaceutical industry during World War II. In 1947, the XII Pan American Sanitary Conference recommended the creation of a committee on drugs and foods to study problems arising from the exportation, importation, manufacture, and supply of drugs, food, and cosmetics, coupled with the establishment of standardization measures to facilitate commercial exchange without sacrificing health objectives. It also recommended that the Bureau take steps to ensure the supply of standards for determining drug potency to official laboratories. In response to the proposals of numerous previous Pan American Sanitary Conferences, the XII Conference ratified the promulgation of a Pan American Pharmacopeia--a project that never came to fruition--and recommended that the countries endeavor to repress the traffic of dangerous or fraudulent drugs, make a general revision of pharmaceutical products and remove any that violated the principles of modern therapeutics, and make the manufacturing licenses renewable for periods not to exceed five years. Quality Assurance Measures When the Bureau became the Regional Office of the World Health Organization (WHO) in 1949, the World Health Assembly, under the WHO Constitution, had already been given the authority to adopt regulations concerning the quality, advertising, and labeling of drugs moving in international commerce. Over the next two decades the Bureau concentrated on ensuring the safety, potency, and purity of drugs and on setting guidelines for their evaluation. With a view to assuring quality from the preparation phase onward, it approved a set of "good manufacturing practices," with which manufacturers of pharmaceutical products were required to comply. These standards have served as a basis for all quality control activities since then. To reinforce them, the Bureau has sponsored numerous courses and workshops, many for its own staff members and inspectors. During the following two decades WHO published the first International Pharmacopeia, and the measures designed to ensure legislative uniformity were strengthened. With the assistance of the Pan American Union, WHO, and the International Union for the Protection of Industrial Property, in 1958 the Pan American Sanitary Bureau [which was known as the Pan American Health Organization (PAHO) beginning that year] established a food and drug control program. At the same time, the Executive Committee suggested that laws be adopted in the countries giving the Governments the authority to regulate research activities and all aspects relating to the purchase, control, registration, inscription, and distribution of drugs in their territories. In support of these measures, PAHO followed the recommendations of the XV Pan American Sanitary Conference, held in 1958, and increased distribution of the most recent publications on therapeutics and pharmacology, organized meetings on the subject, and provided resources for the training of specialists in control techniques. The 1950s brought increased awareness of the damage that could be done by irresponsible and false advertising of products. A number of strongly worded warnings were issued against "miracle drugs," and in 1960 the Directing Council recommended the prohibition of any false and misleading advertising that would diminish the benefits of drug control laws. Following a lengthy study, PAHO determined to undertake a closer examination of certain aspects of the problem, particularly the potential teratogenicity of some drugs. In 1962, the XVI Pan American Sanitary Conference recommended that congenital defects be noted in certificates of fetal death and live birth and that all pharmaceutical preparations, both imported and of national manufacture, be subject to a qualitative inspection. Bearing in mind the latter recommendation, in 1965 PAHO began working toward the establishment of official international quality control laboratories, which would later become important centers for research, reference, and training. It also began to sponsor annual meetings for the officials responsible for food and drug control in Central America and Panama. During the 1960s PAHO espoused policies aimed at extending the drug supply services from the tertiary to the primary care level while at the same time continuing its efforts to ensure the quality of food and drugs and strengthening control activities in the Region. The first Seminar on Drug Control in the Americas, held in 1970 and sponsored by PAHO and the Government of Venezuela, emphasized the importance of adequate training for auxiliary personnel and clinical pharmacologists and the need to standardize existing policies. Consumers were the focus of increasing attention, as was brought to light in 1972 when the XV World Health Assembly urged the Member Governments to provide their populations with information about the use, hazards, and limitations of drugs. At the same time it requested them to study the shelf life of pharmaceutical products and the maintenance of records and a system of certification to guarantee good quality. The Regional Program on Essential Drugs After the Declaration of Alma Ata (1976), PAHO turned its attention to the cost and availability of drugs. It was recognized that if the target of "Health for All by the Year 2000" was to become a reality, taking into account the rapid growth of the population, a larger portion of the limited budget of the Ministries of Health would have to be devoted to therapeutic agents as key elements in the control of morbidity. However, it was also recognized that there were too many brand-name products in circulation that did not correspond to the basic health needs and economic capacity of the countries. WHO responded to this situation by preparing a list of essential drugs--using only international nonproprietary names--based on criteria of cost, effectiveness, and safety. Inspired by this example, almost all the countries in Latin America and the Caribbean succeeded in preparing their own therapeutic formularies, or basic drug tables, by the mid-1980s. These have been reviewed periodically with a view to adding or deleting products based on an assessment of their relative benefits and risks. Since 1978, decisions regarding the safety and effectiveness of drugs have been published in a special section of the Boletín entitled "Información farmacológica." Following the initiative of WHO, in 1983 PAHO launched the Regional Program on Essential Drugs, which has two fundamental objectives: to support the development and application of basic tables and to help the countries to create national drug programs and policies based on their national health needs, their profile of supply and demand, and the supply capacity of their industrial sectors. Between 1984 and 1989, PAHO published a sequence of important works that included such titles as: Elaboración y utilización de formularios de medicamentos [Development and Implementation of Drug Formularies], Políticas de producción y comercialización de medicamentos esenciales [Policies for the Production and Marketing of Essential Drugs], Clasificación Internacional de Medicamentos [International Classification of Drugs] (a document prepared in collaboration with WHO), Manual para la administración de farmacias hospitalarias [Manual for the Administration of Hospital Pharmacies], and Pautas para el establecimiento de un programa nacional de control de medicamentos [Guidelines for the Establishment of a National Drug Control Program]. Despite the favorable impact of the foregoing measures, the cost of drugs escalated and problems relating to the administration of supply systems intensified during the economic crisis of the 1980s. In response to this situation, PAHO concentrated its efforts on improving the efficiency of supply systems and fostering self-sufficiency in the countries through promotion of the manufacture of generic products at the national level and the use of traditional drugs of proven safety and efficacy. It also began to provide support for financial and administrative mechanisms designed to facilitate joint purchasing of drugs by public sector entities. Reiterating its traditional support for regulatory agencies, in 1984 the Organization sponsored the formation of the Latin American Network of Official Drug Quality Control Laboratories. The Network's sphere of action was extended to encompass drug registration and regulation by the Ibero-American Meeting on the Registration, Inspection, and Quality Control of Drugs, held in Madrid in 1991. Policies on the production and marketing of essential drugs were a central focus of the XXIX Meeting of the Directing Council of PAHO in 1984, an important event at which considerable time was devoted to discussion of the drug situation in specific countries of the Region, as well as at the level of subregional markets. Today the multinational nature of many PAHO projects in the area of drugs is an outgrowth of the need to bring regulatory and normative criteria into line in order to respond to the processes of economic and political integration that are taking place in the Region. Most projects are carried out in the context of the PAHO subregional initiatives involving the Central American and Andean countries (the Plan for Priority Health Needs in Central America and Panama and the Andean Cooperation in Health), which assign priority to essential drugs. Rational Use of Drugs With the advent of the 1990s, the rational use of therapeutic agents has begun to occupy a prominent place in the policies of the Regional Program. In this context, one of the biggest challenges facing PAHO is to overcome the enormous resistance of professionals and the public at large to the use of generic drugs for purposes of prescription, dispensing, and consumption. In order to ensure the correct utilization of therapeutic agents, it will be necessary, basically, to modify the way in which physicians and pharmacists are trained and to awaken in the latter an awareness of their vital role as true experts. In 1990 the first Pan American Conference on Pharmaceutical Education was held in Miami. The declaration of principles regarding the role of pharmacists that emanated from that Conference has led pharmacy schools throughout the Region to undertake an in-depth revision of their curricula. In order to enhance education in this area, PAHO has created various centers in Central America and the Andean area to disseminate up-to-date information. The Organization itself is continually disseminating information through a variety of publications, many of them widely distributed reference materials. Notable among these are the Spanish-language version of the eighth edition of USP Drug Information for the Health Professional, which comprises two volumes and is published under an agreement signed by PAHO, the Convention of the United States Pharmacopeia, and the Ministry of Health and Consumer Affairs of Spain. This work is a prestigious international source of information on drugs for health professionals. Looking Toward the Future The Regional Program on Essential Drugs continues to grow rapidly thanks to its capacity and willingness to respond to the true needs of the peoples of the Americas. While at the outset the Program was concerned chiefly with regulation, today its scope has expanded to include all drug-related matters, from the selection, purchase, distribution, labeling, and quality control of drugs to their prescription and use. Increasing multidisciplinary involvement in this area poses a challenge for the future, particularly in view of the difficulty of coordinating the interests of all the sectors concerned, but it is precisely this characteristic that will ensure vitality and progress. The Latin American Conference on the Economic and Financial Aspects of Drugs, held in Caracas, Venezuela, in March 1992, was one of the first clear demonstrations of the way in which the pharmaceutical and economic sectors today are inextricably linked. The Regional Program on Essential Drugs receives ongoing support from the WHO Action Program on Essential Drugs, the United States Food and Drug Administration, the Canadian Health Promotion Branch, the Ministry of Health and Consumer Affairs of Spain, and the American Association of Colleges of Pharmacy (AACP), as well as a number of other public and private entities in the member countries. The Program is funded mainly through extrabudgetary funds from WHO and projects with donor agencies. The pharmaceutical industry also provides support through its national and international associations. It is difficult to predict exactly what direction the Program will take in the future but its course will undoubtedly be determined by the technical innovations and epidemiological, economic, political, and ideological trends that develop along the way. It will almost certainly have to grapple with the challenges created by the biotechnological revolution, for example, as well as the growing incidence of chronic and environmentally related diseases in the developing countries. The PAHO Regional Program on Essential Drugs has heretofore been, is now, and will continue to be a valuable instrument for the Governments of the Americas in their effort to secure health and well-being for their peoples. ILLUSTRATIONS FROM THE FLORENTINE CODE (Scattered, no caption) PHOTO OF THE SPANISH-LANGUAGE VERSION OF THE U.S. PHARMACOPEIA The Spanish-language version of the Eleventh Revision of the United States Pharmacopeia incorporated a number of changes which were the product of study and practice during the year and a half that followed publication of the original work. PHOTO OF ILLUSTRATIONS OF "MIRACLE" PRODUCTS (no caption) PHOTO OF SLIDES 461 AND 472B The consumer is increasingly perceived as someone who demands to know what he or she is buying and who desires to participate in the programming of development and to contribute to the ongoing education process which is the basis of progress. Dr. Abraham Horwitz Director of PAHO, 1959-1975 PHOTO OF SLIDES 996 and 001009 Through its initiatives, PAHO is endeavoring to rectify the uneven distribution of pharmaceutical products between the public and private sectors. PHOTOS OF SCIENTIFIC PUBLICATIONS 474, 462, 525, PNSP 88-29, PNSP 87-05 & PNSP 89-10 (no caption) PHOTO OF SLIDES 521, 666 Proper training of pharmacists is essential to the success of essential drug programs. Training activities are currently a major focus of attention for PAHO. PHOTO OF SLIDE 631 It is counterproductive to have drugs expire on the shelf as a result of administrative inefficiency. PAHO is devoting a great deal of effort to modernizing the drug supply and distribution systems in its member countries. PHOTO OF THE NATIONAL THERAPEUTIC FORMULARY OF COLOMBIA Essential drugs formularies are intended to help meet therapeutic needs in the health systems. Consequently, they can be prepared for the entire health sector of a country, a specific health program, a rural dispensary, an urban clinic, a hospital, or any other health service unit. Such formularies have been developed by the countries, with the collaboration of PAHO/WHO, in response to the need to control costs while at the same time assuring quality. PHOTOS OF SLIDES 596, 599, 601 Manufacture of pharmaceutical products at the national level and the use of generic drugs are two of the measures that PAHO is promoting in order to reduce costs and improve the availability of products. E0258.FIN EVENTS AND/OR SHORT COURSES IN THE ENVIRONMENTAL HEALTH FIELD WHICH WILL BE SUPPORTED BY PAHO IN 1992 COUNTRY: NAME: OBJECTIVE: DURATION AND DATE PROGRAMMED FOR EXECUTION: LEVEL AND CHARACTERISTICS OF THE PARTICIPANTS: NATIONAL ORGANIZING BODY (IF APPLICABLE): CAN PARTICIPANTS FROM OTHER COUNTRIES BE ACCEPTED: YES NO IF YES, INDICATE WHERE THEY ARE TO REGISTER: PAHO COLLABORATION: 1 2 3 4 STAFF MEMBER IN CHARGE: 1. Organization and Execution 2. Financing 3. Presentation of Classes 4. Material and Equipment PAHO/WHO MEMORANDUM Date: 5 June 1992 From: H. Otterstetter, CP/HPE To: Those mentioned at bottom* Our Ref: HPE/85/1/RC/141 Attention: Your Ref: Subject: Catalogue of events and/or short courses in environmental health field (1992) Originator: R. Castro For your information, we enclose a copy of the catalogue of events and/or short courses in the environmental health field which will be supported by PAHO during 1992. This document has been prepared on the basis of the contributions from the countries which appear in it. In order to supplement and keep this information updated, and possibly to facilitate the participation of different countries in the courses announced, we plan to publish new editions next August and October. In order to be able to do this, we request your collaboration in sending us the necessary information by the 15th of the months indicated. We will be grateful if you duplicate and utilize the format which is included at the end of the enclosed document for this purpose. Thank you for your attention. Attachment ANNEXES 1. Information on the PAHO Regional Symposium on "Evaluation and Management at the Local Level of Environmental Risks to Health." 2. Information on lodging. 3. Matters to consider in obtaining visas to travel to Cuba. 4. Information on the XXIII AIDIS Congress. 5. Informative pamphlets on the courses to be given before the AIDIS Congress. 1. BACKGROUND In July 1972 the United Nations Conference on the Environment, held at Stockholm, focused the world's attention on environmental risks which threaten human health. Since then many countries and organizations have to a greater or lesser degree made efforts to minimize such risks. Nevertheless, the impact on the environment caused by rapid urbanization and population growth, together with industrial development, has resulted in the magnitude of the environmental problems which have adverse effects on human health increasing instead of declining. In Latin America and the Caribbean, this situation has been aggravated by the economic and social problems which many of the countries are facing, negatively affecting their environmental health policy, which in turn has produced an increase in the number of health problems related to the environment. The epidemic of cholera which is affecting the Region dramatically illustrates the severity of these problems. Although cholera had been identified as a problem of Asia and later Africa, once the disease was introduced to Latin America the existing deficient environmental situation provided ideal conditions for its rapid dissemination. Thus, the Region began to pay a new debt, an Environmental Health debt which had been accumulating during the past two decades through lack of attention to environmental health problems. If this situation persists and increased attention is not paid to solving existing deficiencies, we can only expect that public health problems similar to those mentioned above will multiply. The European Charter on Environment and Health, signed at Frankfurt in December 1989 by representatives of the countries of that Region, points out "the vital importance of preventing risks to health through the protection of the quality of the environment." It also recognizes the right of each individual to live in an environment that permits him to achieve the highest level of health and well-being. Throughout the developing world, however, the nature of the problem is broad and complex, comprising multiple and interconnected causes and many diseases. For some countries the greatest challenge in environmental health is lack of drinking water; in others there are simultaneous and contrasting situations such as those that occur under conditions of extreme poverty and those due to intense economic development and industrialization promoted by the urgent needs of a growing population. Everyone's health is affected by the environment. While new concerns are arising in the urban environment, environmental problems still persist in the rural environment. Many environmental pollution problems are not confined to the rural or to the urban environment: they know no geographical borders. Contamination of natural resourcesÐwater, air, and soilÐaffects all. Such problems also affect every social stratum: rich and poor eat contaminated food, drink unsafe water, and breathe polluted air, but deterioration of the environment has a greater impact on the poor, and women and children are exposed to greater risk. Within this context, to speak of the framework for an environmental health program is to speak of inter-professional cooperation and community participation as pillars of activities which will make it possible to improve public health. In view of the foregoing and especially the importance of community participation for the success of activities which are adopted to control the environmental risks at the local level, the Pan American Health Organization has thought it desirable to devote this Symposium to the subject of "Evaluation and management at the local level of environmental risks to health." 2. OBJECTIVES To identify factors that help the community participate in solving its environmental problems. To generate guidelines which for the countries facilitate the formulation of programs to control environmental risks at the community level. 3. PARTICIPANTS Professionals from Ministries of Health, other sectors of public and private entities, and ONGs which act to protect and control the environment in the countries of the Region of the Americas and the Caribbean. Representatives from international cooperation agencies which support the sector. PAHO/WHO staff members. 4. STRUCTURE OF THE SYMPOSIUM AND METHODOLOGY OF WORK There are three blocks of activities, with the objectives and characteristics indicated below. FIRST BLOCK To present the principal environmental risks to human health; recommend activities for their identification, evaluation, and control at the local level, and mechanisms applicable to the mobilization and social participation of communities for environmental action. This block will be made up of conferences followed by a discussion period. SECOND BLOCK To determine and analyze local experiences in management and control of environmental risks, and to identify the factors which, in such experiences, have contributed to community participation in solving environmental problems. In this block the experiences of several countries and institutions in developing integrated environmental health programs at the local level will be presented through conferences, highlighting community organization and forms of action. In working groups, the participants will then analyze the experiences presented and will attempt to identify factors contributing to community participation. The final activity in this block will be a plenary session in which the groups will present and discuss the factors they identified. THIRD BLOCK Analysis and discussion in working groups of the items presented in the two previous blocks. On that basis, and with their personal experiences, to define the principal points which should be considered in formulating and applying a plan to prevent and control environmental risks at the local level, and identify recommended strategies for its implementation, as well as the organizations which should participate. Following the work of the groups, the results will be presented and discussed at a plenary session and recommendations will be formulated for intensifying the mobilization of the community in solving its environmental health problems in the Region.AGENDA OF THE REGIONAL SYMPOSIUM ON EVALUATION AND MANAGEMENT AT LOCAL LEVEL OF ENVIRONMENTAL RISKS TO HEALTH 17-19 of November 1992 Havana, Cuba 17 NOVEMBER18 NOVEMBER19 NOVEMBERMORNINGOPENING BLOCK 1 Environmental risks Their identi-fication, evaluation, and control at the local level Community mobilization for environmental action Local experiences in managing and controlling environmental risks BLOCK 3 Work in groups Definition of main points of a plan to prevent and control environmental risks at the local level Identification of strategies for implementation Recommendations BREAK (12:30-14:00)AFTERNOONContinuation. BLOCK 2 Local experiences in managing and controlling environ-mental risks. Work in Groups Identification of factors contributing to community par- ticipation in solving its environ-mental problems Plenary Session Presentation and discussion of results from the working groups. Continuation of Work in Groups Plenary Session Presentation and discussion of results from the working groups Recommendations of the Symposium. CLOSURE ENCLOSURE II INFORMATION ON LODGING In asking the PWR/Cuba and the Organizing Committee of the XXIII AIDIS Congress to help reserve lodging for PAHO staff members and participants in the Symposium which HPE will conduct during the week before the Congress, we were informed that to facilitate their transportation to the site at which the Symposium will be held (the Palace of Conventions) it would be necessary for all to be lodged in a single hotel. The options were analyzed and it was found that the most desirable would be the Bio-Caribbean Hotel. This hotel was opened in 1991 and has very good facilities, and the meeting of HPE/PAHO staff will be held in its conference room on 20 and 21 November. The Bio-Caribbean Hotel has set a special reduced rate for the participants in the PAHO Symposium and has committed itself to reserve the necessary number of rooms. Since there will be several international events with a high demand for lodging in Havana in November, however, we were told that we should confirm the total number of persons for whom rooms are to be reserved by 20 July. To be able to meet this requirement, it is necessary that each PWR advise HPE by 15 July of the number of persons who will travel to Cuba for the PAHO Symposium. If PAHO staff members travel with family members, they should indicate their number and how many rooms they wish reserved for them. To facilitate Symposium participants remaining in Cuba for the AIDIS Congress, an effort was made to diminish costs for lodging, transportation, and feeding. For this purpose, the Organizing Committee of the Congress was asked to prepare a "tourist package" including those items similar to the one it prepared for persons who will attend only the Congress. The following pages include an informative pamphlet from the Bio-Caribbean Hotel and the cost of the tourist package coordinated by the Organizing Committee of the AIDIS Congress. Two options appear in the costs shown, the first for persons who will attend only the PAHO Symposium, and the second for persons who will remain in Cuba to the end of the Congress. In both cases, the cost of the tourist package has been calculated taking into account the special rates of the Bio-Caribbean Hotel for lodging and food, and transportation includes that from the Hotel Bio-Caribbean to the Palace of Conventions and vice versa. The term "meals" in the enclosed information refers to suppers since at noon the participants will be at the Palace of Conventions and the cost of meals there will be paid at the time by each person. Depending on consumption, that cost may vary from U$9 to U$20 each time. To facilitate coordination of transportation from the airport to the hotel, the airline and day and hour of arrival of each participant will have to be reported to the PWR-Cuba a week before the planned date of arrival in Cuba. ENCLOSURE III ASPECTS TO CONSIDER IN OBTAINING VISAS TO TRAVEL TO CUBA 1. The PWR Cuba has offered to collaborate in obtaining visas for all the participants in the PAHO Symposium. To be able to do this, it is necessary that each PWR send the PWR Cuba the following data about each person at least 45 days before the planned date of the trip: Name and two surnames Date of birth Country of birth Current nationality Passport number Place and date of issuance of the passport Date of expiration of the passport. 2. The place and/or way in which visas will be delivered to participants in each country will vary according to whether a Cuban Embassy or Interests Office exists in the country. In countries without such offices, the PWR in the country should indicate for each person where the visa is to b