charting the future

　　by the end of the 20th century we could be living in a world without poliomyelitis, a world without new cases of leprosy, a world without deaths from neonatal tetanus and measles, a world without dracunculiasis. in 1993 measles killed nearly 1.2 million children and infected more than 45 million; poliomyelitis killed 5 500 children and as of that year 10 million people were disabled; leprosy killed 2 400 people and infected 600 000; neonatal tetanus killed 560 000 newborn babies; dracunculiasis infected 2 million people.

　　by the end of the century maternal mortality could be half what it was in 1993, when more than 500 000 women died in childbirth. infant mortality rates could be no higher than 50 per 1 000 live births. at least 70 countries had higher rates than this in 1993. by 2000 mortality of children under 5 years could be no more than 70 per 1 000 live births. at least 60 countries had higher rates than this in 1992. we could be living in a world where less than 10% of babies are born weighing under 2.5 kg. in 1990, 17% of babies were born below this weight. for babies born at the beginning of the 21st century life expectancy could be at least 60 years in every country of the world. in 1993, 50 countries were below this target.

　　in the year 2000 at least 85% of the world s population could be within one hour s distance of medical care. in 1993, about 1 billion people had no access to local health services within a one-hour journey. deaths from malaria could be cut by a fifth in at least 75% of affected countries; the number of deaths and new infections from tuberculosis could be substantially reduced; the number of new carriers of hepatitis b could fall by 80% as a result of childhood vaccination; deaths from heart disease in people aged under 65 could be reduced by at least 15%; all pregnant women could have proper care.

　　the year 2000 could see a world where malnutrition among children under 5 years will fall by 50%; where micronutrient deficiencies from vitamin a and iodine will be eliminated; where the prevalence of iron deficiency anaemia in women of childbearing age will be reduced by 33%; and where 85% of the population will have access to safe water and 75% to safe sewage disposal.

　　these are neither utopian goals nor na?ve wishes for a perfect world. they are achievable - provided the world cares enough and the necessary resources are made available. who sees four main priorities for action in the future.

　　the first priority is to ensure 'value for money' by using the available resources as effectively as possible and redirecting them to those who need them most. the aim is to create self-help environments in which men and women can solve their own problems, establishing and sustaining a development process that will ensure a brighter future for their children.

　　the second priority is poverty reduction through better health. investing in health saves money as well as lives. it must be accepted that expenditure on health is not a drain on national resources but a prerequisite for economic and social progress. poor health inhibits an individual s ability to work, reduces earning capacity and deepens poverty. poverty should thus be tackled on two fronts: one to meet people s basic minimum needs including access to health services, housing and education; the other to provide opportunities for people to earn their way out of poverty through better health and increased productivity. in addition to the economic aspect there is another side to poverty which must be corrected - social discrimination and low status for some groups, particularly women.

　　the third priority relates to public health policy, which in the decade of the 1990s has been influenced not only by the health-for-all movement, with its emphasis on equity, but also by political and economic changes in the world at large. at the same time it is recognized that ensuring equal access to health care, a traditional goal of public health authorities, will not necessarily reduce gaps in health status insofar as disease is determined by individual behaviour and by the working and living environment. any genuine improvement in health will thus call for integrated, intersectoral action in addressing all the determinants of ill-health. the training of health professionals will have to be reoriented accordingly.

　　the fourth priority is to strengthen national capabilities for emergency relief and humanitarian assistance in the health sector. the new policy of 'emergency management for sustainable development' will provide a bridge between relief work and development proper, the aim being to reduce human suffering and economic loss due to epidemics, complex emergencies and mass population displacements.

　　the health problems of the future are awesome. yet much can be done to tackle them with what we know already. in order to succeed the world will have to care more, and try harder, but the situation is not hopeless. martin luther king, writing about the civil rights struggle in the united states in the 1960s, said:'we shall have to repent in this generation, not so much for the evil deeds of wicked people, but for the appalling silence of the good people'.

　　today, as a new generation approaches a new century, it is time for the appalling silence over global health inequities to be broken.

　　the evolution of who

　　the first world health assembly, held in june 1948 and attended by 53 delegates from who's 55 member states, approved a programme of work that listed its top priorities as malaria, maternal and child health, tuberculosis, venereal diseases, nutrition and environmental sanitation.

　　today, 47 years later, in spite of significant improvements in human health, great burdens of suffering and disease are still with us. half a century of lessons learned in eradicating and controlling diseases, expanding health care coverage and making the best use of available resources have guided the world community, including who, on the way to further progress.

　　the need for a world health organization

　　at the end of the second world war the majority of the world's people were still living in extreme poverty and suffering from chronic malnutrition, communicable diseases and parasitic infections to name a few. many existing health services were severely disrupted and huge segments of the population were excluded from them. the imperative need was therefore recognized for a new world body capable of grouping resources for health, concerting health goals and providing a forum for the exchange of health information. the result was the setting up by the united nations of a specialized agency to fulfil that need - the world health organization.

　　declaring war on disease

　　who's first two decades were dominated by mass campaigns to control diseases such as leprosy, malaria, smallpox, syphilis, tuberculosis and yaws. between 1950 and 1965, for instance, 46 million patients in 49 countries were successfully treated with penicillin against the tropical disease yaws, making it no longer a significant public health problem in most of the developing world. by 1955 the number of malaria cases worldwide had dropped by at least one-third; but by 1970 eradication of the disease was seen to be impracticable.

　　the same was not true of smallpox. an eradication campaign that began in 1966, when up to 2 million people a year were dying of smallpox, ended in 1980, when the disease had disappeared from the face of the earth.

　　these mass campaigns against single diseases gave way to who's expanded programme on immunization aimed at protecting by the year 2000 all children against six vaccine-preventable diseases - measles, diphtheria, pertussis, tetanus, poliomyelitis and tuberculosis. global coverage with the vaccines reached its peak in 1990, when the goal of immunizing 80% of all children by the age of 1 year was achieved. the long-term goal of the multiagency children s vaccine initiative, launched in 1990, is to achieve a world in which all people at risk are protected against vaccine-preventable diseases, if possible by means of a single procedure.

　　health for all

　　in 1979 the world health assembly unanimously endorsed the declaration of alma-ata, which stated that primary health care was to be the key to attaining the goal of health for all by the year 2000.

　　consequently global targets for health were established and have since been the norms against which all health development efforts have been measured. the strategy of health for all has been endorsed at the highest political level, but a gap remains between what is preached and what is practised.

　　setting the standards

　　the establishment of standards in such fields as vaccines, drugs and laboratory tests has been a permanent part of who's work. the who expert committee on biological standardization has met every year since 1951 to formulate standards which are recognized worldwide. the scientific credibility of who provides a guarantee that everyone accepts.

　　training physicians, raising the standards of medical schools in developing countries and helping countries organize schools for nurses and midwives has also been a permanent feature of who's work. the concept of primary health care has switched much of the emphasis to training directed towards a wide range of health care workers at community level, particularly in developing countries, rather than towards health professionals as such.

　　the way ahead

　　who's general programmes of work, now covering periods of six years, set out principles and policies for the functioning of the organization. they also provide a framework for detailed workplans and budgeting. over the years the programmes have responded to, and often anticipated, the major health concerns of member countries. the ninth programme (1996-2001) fixes goals and targets for who's global health action. it focuses on lessening of inequities in health, control of rising costs, the eradication or elimination of selected infectious diseases, the fight against chronic diseases, and the promotion of healthy behaviour and a healthy environment.

　　the challenge for the future is to mobilize who's member states to adopt policies and plans that will guarantee the provision of comprehensive integrated health services for all.