A45/VR/7

7 May 1992 7 mai 1992

FORTY-FIFTH WORLD HEALTH ASSEMBLY

QUARANTE-CINQUIEME ASSEMBLEE MONDIALE DE LA SANTE

•

叙 WORLD HEALTH ORGANIZATION

^ ORGANISATION MONDIALE DE LA SANTE

PROVISIONAL VERBATIM RECORD OF THE SEVENTH PLENARY MEETING

Thursday, 7 May 1992, at 9h00 Palais des Nations, Geneva

President: Mr A. AL-BADI (United Arab Emirates) later Acting President: Dr N. NGENDABANYIKWA (Burundi)

COMPTE RENDU IN EXTENSO PROVISOIRE DE LA SEPTIEME SEANCE PLENIERE

Jeudi, 7 mai 1992, 9 heures Palais des Nations, Genève

Président : M. A. AL-BADI (Emirats arabes unis) puis Président par intérim: Dr N. NGENDABANYIKWA (Burundi)

CONTENTS

Page

Debate on the reports of the Executive Board on its eighty-eighth and eighty-ninth sessions and on the report of the Director-General on the work of WHO in 1990-1991 (continued) 3

SOMMAIRE

Page

Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-huitième et quatre-vingt-neuvième sessions et sur le rapport du Directeur-général sur l'activité de l'OMS en 1990-1991 (suite) 3

A45/VR/6 • page 2

Note: In this provisional verbatim record speeches delivered in Arabic, Chinese, English, French, Russian or Spanish are reproduced in the language used by the speaker; speeches delivered in other languages are given in the English or French interpretation.

This record is regarded as provisional because the texts of speeches have not yet been approved by the speakers. Corrections for inclusion in the final version should be handed in to the Conference Officer or sent to the Records Service (Room 4013, WHO headquarters), in writing, before the end of the session. Alternatively, they may be forwarded to Chief, Office of Publications, World Health Organization, 1211 Geneva 27，Switzerland before 3 July 1992.

Note : Le présent compte rendu in extenso provisoire reproduit dans la langue utilisée par l'orateur les discours prononcés en anglais, arabe, chinois, espagnol, français ou russe, et dans leur interprétation anglaise ou française les discours prononcés dans d'autres langues.

Ce compte rendu est considéré comme un document provisoire, le texte des interventions n'ayant pas encore été approuvé par les auteurs de celles-ci. Les rectifications à inclure dans la version définitive doivent, jusqu'à la fin de la session, soit être remises par écrit à l'Administrateur du service des Conférences, soit être envoyées au service des Comptes rendus (bureau 4013, Siège de l'OMS). Elles peuvent aussi être adressées au Chef du Bureau des Publications, Organisation mondiale de la Santé, 1211 Genève 27, cela avant le 3 juillet 1992.

Примечание； В настоящем предварительном стенографическом отчете о заседании выступления на ан-глийском, арабском, испанском, китайском, русском или французском языках воспроизводятся на языке оратора; выступления на других языках воспроизводятся в переводе на английский или фран-цузский языки.

Настоящий протокол является предварительным, так как тексты выступлений еще не были одоб-рены докладчиками. Поправки для включения в окончательный вариант протокола должны быть пред-ставлены в письменном виде сотруднику по обслуживанию конференций или направлены в Отдел доку-ментации (комната 4013, штаб-квартира ВОЗ) до окончания сессии. Они могут быть также вручены до 3 июля 1992 г• заведующему редакционно一издательскими службами, Всемирная организация здраво-охранения, 1211 Женева 27, Швейцария.

Nota: En la presente acta taquigráfica provisional, los discursos pronunciados en árabe, chino, español, francés, inglés 0 ruso se reproducen en el idioma utilizado por el orador. De los pronunciados en otros idiomas se reproduce la interpretaci¿n al francés o al inglés.

La presente acta tiene un carácter provisional porque los textos de los discursos no han sido aún aprobados por los oradores. Las correcciones que hayan de incluirse en la versión definitiva deberán entregarse, por escrito, al oficial de Conferencias o enviarse al Servicio de Actas (despacho 4013, sede de la OMS) antes de que termine la reunión. A partir de ese momento, pueden enviarse al Jefe de la Oficina de Publicaciones, Organización Mundial de la Salud, 1211 Ginebra 27, Suiza, antes del 3 de julio de 1992.

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A45/VR/6 • page 3

DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS EIGHTY-EIGHTH AND NINTH SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN 1990-1991 (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-HUITIEME ET QUATRE-VINGT-NEUVIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR-GENERAL SUR L'ACTIVITE DE L'OMS EN 1990-1991 (suite)

The PRESIDENT:

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El Dr. VASQUEZ SOSA (El Salvador):

Señor Presidente, señor Vicepresidente, señor Director General, señor Director Regional para las Américas, señores ministros, señores delegados: quisiéramos agradecer al Todopoderoso por permitirnos asistir a esta Asamblea y expresar, en nombre de Centroamérica, nuestra felicitación al señor Presidente por su elección en esta 45* Asamblea Mundial de la Salud, deseándole el mejor de los éxitos a los trabajos de esta Conferencia y pidiéndole al Creador que redunden en hacer realidad el sueño de «Salud para todos en el año 2000». Quisiera expresar mi especial satisfacción y agradecimiento por este privilegio y por el honor de poder dirigirnos a esta magna Asamblea en nombre de las naciones hermanas del istmo Centroamericano.

Por primera vez en nuestra historia ondea en todos nuestros países la bandera de la democracia y, por otro lado, vislumbramos en nuestro horizonte el ansiado arco iris de la paz, como augurio de la esperanza, del progreso y el desarrollo de nuestra región. Después de estos años de dolor y sufrimiento, los centroamericanos hemos aprendido que la tragedia ha hecho más fuertes nuestros lazos fraternos y nos ha vuelto más humanos y solidarios. Como en toda familia, el dolor ha dado fuerza, energía y vigor a nuestros corazones; ha hecho prevalecer el amor sobre el odio, la razón y el entendimiento sobre la violencia. La bondad y la comprensión norman nuestras actitudes. Hoy, más que nunca, vemos claro que tenemos el mismo camino y destino, como ha sido el sueño de nuestros antepasados.

La historia sabiamente nos señala nuevamente nuestro derrotero. Dan un ejemplo los pasos que han seguido nuestros presidentes, desde la primera reunión en Esquipulas, hasta la reunión de Tegucigalpa, para examinar conjuntamente los desafíos políticos, económicos y sociales y procurar solucionarlos conjuntamente. Dan una muestra del espíritu centroamericano, de nuestras potencialidades y de lo que vamos a hacer en la era que tenemos por delante con un nuevo orden mundial en construcción. Cesó la confrontación entre Este y Oeste, la cual tuvo mucho que ver con nuestra historia pasada.

Fue en la cumbre realizada en Tegucigalpa, Honduras, donde se puso como prioridad el desarrollo humano de la infancia y la juventud, con el lema: «porque los seres humanos somos lo más importante». Se abordó la problemática humana y la necesidad de crear programas de compensación social (en salud, vivienda, educación y seguridad alimentaria), enfatízando la necesidad de la salud para un desarrollo humano con equidad. En esta cumbre se ratifica el Consejo de Ministros de Centroamérica como organismo de más alto nivel que mantendrá la conducción y coordinación de los diferentes programas y acciones subregionales. Estas acciones incluyen: los programas de fortalecimiento de la infraestructura de los servicios de salud en Centroamérica, la desconcentración, la descentralización, la administración estratégica local, la participación social, el desarrollo de los recursos humanos y el fortalecimiento de la capacidad gerencial dentro de la táctica operativa de los SILOS contenidos en la segunda fase de la iniciativa de la Reunión del Sector de Salud de Centroamérica y Panamá, a saber «salud y paz hacia el desarrollo y la democracia».

El fin último de toda sociedad es la persona humana y, dentro de las medidas de reajuste económico necesarias e indispensables para liberar nuestras economías, no debemos olvidar que antes de todo somos seres humanos. Debemos humanizar todas las medidas, buscando que los resultados de la balanza sean positivos y encuentren avenidas que logren que todos los sectores de la sociedad, sobre todo los más postergados, reciban los beneficios derivados del sacrificio económico en la búsqueda del bienestar. Actualmente estamos encaminados, como parte de la compensación y la deuda social acumulada, a resolver problemas de salud de nuestra región Centroamericana, donde el esfuerzo conjunto y hermano ha logrado en esta nueva visión con rostro humano, la extensión de la cobertura de la atención y la mejora de la eficiencia, de la eficacia y de la equidad. Ejemplo de esto es la eliminación de la poliomielitis y los altos niveles de vacunación. También se plantean nuevos desafíos: la eliminación de la rabia humana, del tétanos neonatal y

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del sarampión, con la ayuda de la OPS y de otros organismos y países amigos. Dentro de estos nuevos retos aparecen y agravan más la situación de salud en la subregión Centroamericana el problema del cólera con 12 000 pacientes, el SIDA que cada día cobra más víctimas, y los desastres naturales que afectan periódicamente a nuestros países, cobrando víctimas y aumentando la aflicción de nuestros debilitados sistemas económicos. Estos problemas dificultan alcanzar la meta de «Salud para todos en el año 2000», y por consiguiente el desarrollo pleno de nuestras nacientes democracias.

Hemos creado ya conciencia de la importancia de la salud y medio ambiente y existe compromiso de nuestros mandatarios para hacerle frente a los mismos con una visión integral de acuerdo a las modernas concepciones estratégicas.

No hay duda de que los indicadores de mortalidad materna e infantil y de desnutrición continúan siendo altos pero también, no es menos cierto al evaluar el impacto de los programas, que es evidente el acelerado mejoramiento a corto plazo de la situación de salud en todos nuestros países. Convencidos de que para afirmar una paz firme y duradera en Centroamérica es indispensable asegurar condiciones de vida adecuadas a nuestros pueblos, y dado que la cooperación internacional es un factor complementario de primer orden a los esfuerzos que realizamos, deseamos expresar nuestro más profundo reconocimiento y agradecimiento a la comunidad internacional por toda la asistencia brindada hasta la fecha. A la vez la instamos a continuar la misma incrementando sus montos, con el objetivo de permitirnos alcanzar en el más corto plazo nuestros objetivos de desarrollo que se cimientan en el concepto de que el desarrollo económico debe estar orientado al servicio de las personas y al mejoramiento de sus condiciones de vida en un medio ambiente sano.

Señor Presidente: Somos fíeles creyentes de que la mayor riqueza de nuestros pueblos son su gente, como demuestran nuestras culturas desde los mayas hasta nuestros días. Es por eso que, en nombre de esta misma sangre que corre en nuestras venas, pedímos en este foro internacional que nos den las oportunidades y apoyo para poder mostrar realmente en esta nueva era mundial la nueva gran familia Centroamericana en paz, democracia, libertad y justicia.

Dr AUSSERWINKLER (Austria):

Mr President, Mr Director-General, distinguished delegates, it gives me great pleasure to address you on this, my first visit to your Assembly. I would like to start by offering you, Mr President, and the Vice-Presidents my congratulations on your election to office. I would also like to thank the Director-General for his report, which reflects his endeavour to strive for the health of all humans in our world.

Although I can only look back to a one month's term of office as Minister of Health of Austria, my relationship to WHO dates back to an earlier time. As deputy-mayor of Klagenfurt, the capital of Carinthia, where I was also responsible for health, housing and pre-school care of children, I succeeded in creating together with politicians from other Austrian cities, a national network of "Healthy Cities". I should like to mention the strong motivating force that seized our administration after we had decided to join the undertaking of intersectoral action for health at the level of our municipality.

The extremely successful "Healthy Cities" project, created by the WHO Regional Office for Europe in Copenhagen, can also serve as a model to demonstrate some characteristic features of successful leadership in health, such as a coherent vision of an overall long-term goal, a strong commitment to meet emerging needs and priorities, respect for cultural and social traditions at the local level, and a skilful use of self-enhancing mechanisms for the formation of an increasing number of skilled and knowledgeable decision-makers committed to a new positive concept of public health. The "Healthy Cities" project also demonstrates that community involvement, or more precisely "community ownership", can also build up a new awareness of solidarity in our societies.

In Austria too, we are finding ourselves in a transition period, having to a large degree already overcome autocratic leadership in health but not yet reached the desirable level of participative leadership. The loss of solidarity can sometimes be frightening, especially when it coincides with a radical exposure of inequities, as we are experiencing just now due to the far-reaching political changes in central and eastern Europe. Inequities in health at all levels - at the national, regional and worldwide level - constitute the most crucial challenge of our time. Only the mobilization of resources of a new order of magnitude will be able to lessen these unbearable shortcomings.

But there remains a further issue，of no less importance, indeed. We should promote the self-confidence a叫 self-esteem of all members of the family of mankind; this should enable us to attain a higher level of solidarity.

Let me conclude by clarifying this with the help of Mozart's "Magic Flute". What is said about Tamino? The answer in the original language is: ”Er ist Prinz\ - And Sarastro clarifies: ”Noch mehr’ er ist ein Menschl” In English: "He is a prince." - "More than that, he is a human being!"

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M. HGUEIREDO SOARES (Cap-Vert):

Monsieur le Président, Monsieur le Directeur général, honorables délégués, Mesdames et Messieurs, permettez-moi tout d'abord, Monsieur le Président, de vous présenter les chaleureuses félicitations de la délégation du Cap-Vert pour votre élection à la tête de cette Quarante-Cinquième Assemblée mondiale de la Santé. Mes félicitations s'adressent aussi aux Vice-Présidents ainsi qu'aux autres membres du bureau. Je suis sûr que, sous votre conduite, la présente Assemblée atteindra pleinement ses objectifs. Nous souhaiterions exprimer aussi nos vives félicitations au Dr Hiroshi Nakajima, Directeur général, pour son rapport biennal sur l'activité de l'Organisation mondiale de la Santé en 1990-1991, lequel traduit de façon claire et précise les énormes efforts déployés dans le monde pour relever les défis et surmonter les différents obstacles qui s'opposent encore à notre marche vers la santé pour tous. Permettez-moi également d'adresser un mot de remerciement à notre Directeur régional, le Dr Monekosso, pour l'appui personnel qu'il ne cesse de donner à la cause de la santé dans notre pays.

Depuis quelques années, il est devenu clair que la résolution des problèmes de santé prioritaires au niveau mondial exige l'introduction de changements profonds et novateurs dans la façon de concevoir et d'organiser les services de santé. Si l'OMS, de son côté, essaie d'apporter une réponse adéquate à ces défis, le vrai succès dépend en dernière instance du degré de mobilisation des différents partenaires impliqués dans le processus de développement sanitaire, à savoir les dirigeants politiques et économiques, les organisations non gouvernementales, la communauté internationale, enfin tous les individus au sein de leur famille, de leur communauté, à tous les niveaux. L'histoire récente de la santé publique dans le monde nous montre que chaque fois qu'il y a mobilisation et motivation suffisantes, les résultats sont énormes. L'évolution de la couverture vaccinale en Afrique est un exemple de ce que pe:,t obtenir la mobilisation de tous autour d'objectifs concrets et réalistes. Tous nos systèmes de santé nationaux ont pour objectif final la prestation de soins de qualité à l'ensemble de la population en utilisant différentes approches stratégiques et des ressources diversifiées. Il est clair, en tout cas, que la clé en est la mobilisation de tous pour la santé pour tous. C'est là, en matière de santé, l'une des plus grandes leçons à tirer de cette fin de siècle marquée par l'émergence de nouveaux cadres de référence qui nous incitent toutefois à cultiver la modestie et la tolérance.

A ce propos, permettez-moi, Monsieur le Président, de penser à haute voix. De combien nos discours de mobilisation et "leadership" pour la santé ne sont-ils pas décalés par rapport à la pratique dans nos Etats et les autres pays du monde qui, depuis des années, se battent pour la santé de leurs peuples ？ Au Cap-Vert, le débat actuel sur le développement sanitaire est axé sur cette grande question, Notre Gouvernement fait des efforts croissants pour soutenir le secteur de la santé, conscient que celle-ci est une condition nécessaire du développement socio-économique. Si nous avons indiscutablement obtenu des résultats, le chemin à parcourir reste encore long et difficile. En effet, les progrès des années à venir dépendront essentiellement de facteurs extrasanitaires tels que l'assainissement, l'approvisionnement en eau potable et la nutrition. Si, dans les pays pauvres et en développement, il est déjà difficile de travailler dans ces domaines, vous comprendrez, Monsieur le Président, chers délégués, qu'il l'est encore bien davantage dans un petit pays sahélien comme le nôtre. Qui dit Sahel dit sécheresse, érosion, manque d'eau, avec tout ce que cela implique pour la nutrition et la santé. Tout ceci pour dire que nos modestes résultats ont été obtenus dans des conditions particulièrement difficiles. Monsieur le Président, si ces progrès ont été possibles, si nous osons regarder l'avenir avec une lueur d'espoir, nous le devons grandement à tous nos partenaires de la communauté internationale qui manifestent leur présence solidaire chaque fois que cela est nécessaire. Permettez-moi donc d'exprimer les sincères remerciements du peuple du Cap-Vert à tous ceux qui contribuent de façon désintéressée à améliorer notre niveau de vie.

Le Cap-Vert vit aujourd'hui une période de consolidation de ses institutions démocratiques qui, nées en 1991 des premières élections démocratiques et libres, ont culminé en décembre dernier avec l'élection d'un pouvoir local autonome et représentatif des intérêts des populations dans tous les districts du pays. Ce processus de démocratisation profonde de notre société offre au système de santé l'occasion unique de se décentraliser pour forger un partenariat actif et dynamique avec les différentes forces sociales auxquelles le processus a lui-même donné naissance. Mon Gouvernement, conscient de cette chance historique, s'est fermement engagé dans un processus de mobilisation de toutes les couches et forces sociales en vue d'asseoir l'action de développement socio-sanitaire sur une forte participation communautaire. Dans ce contexte, nous attachons une très grande importance au thème des discussions techniques de cette année, espérant en tirer le meilleur parti possible pour le renforcement du "leadership" de nos femmes en faveur de la santé. J'ose également espérer que les femmes du moode entier s'engageront davantage et plus fermement dans ce processus, contribuant de façon décisive à la construction de la paix, de l'entente entre tous les peuples dans un esprit de tolérance et de compréhension, condition préalable de la santé pour tous. Pour terminer, permettez-moi, Monsieur le Président, de rendre un hommage tout particulier à ce grand forum de la santé, source

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d'inspiration et d'espoir, qui réunit grands et petits dans la poursuite d'un même objectif ultime : ramélioration de la qualité de vie de la population de notre planète, finalement bien petite.

Dr N. Ngendabanyikwa (Burundi), Vice-President, took the presidential chair. Le Dr N. Ngendabanyikwa (Burundi), Vice-Président, assume la présidence.

Le PRESIDENT par intérim :

Je remercie le délégué du Cap-Vert pour son discours très éloquent et plein d'utiles informations. Avant de donner la parole au prochain orateur, je voudrais d'abord m'acquitter d'un agréable devoir, celui de remercier très sincèrement l'Assemblée de la confiance qu'elle m'a témoignée en me confiant la lourde mission d'assurer la vice-présidence de la présente Assemblée. Je compte sur votre habituelle collaboration afin que nous puissions accomplir à votre entière satisfaction la tâche que vous nous avez confiée. J'invite le délégué de la Finlande à venir à la tribune et je donne maintenant la parole au délégué du Mozambique.

Dr IGREJAS CAMPOS (Mozambique):

Mr President, Mr Director-General, Members of the Presidium, distinguished delegates, ladies and gentlemen, on behalf of my Government and the Mozambican delegation to this Assembly, I would like to congratulate the President and other members of the Presidium for their election, and wish them success in leading the works of our Assembly. I also want to congratulate the Director-General for the excellent report submitted to this Assembly on the work of WHO for the biennium 1990-1991.

I was expecting to announce in this Assembly that peace had finally reached my country. Unfortunately, this important event hasn't happened yet. The war is still devastating Mozambique because of further delays in peace talks in Rome. These delays are mainly due to new unexpected points in the agenda that the armed opposition - Renamo - wants to include to the peace talks for Mozambique in Rome.

During the last three years we have witnessed several political changes，namely: a new Constitution approved by the Parliament (National Assembly) instituted a multiparty system and introduced the system of market economy. These fundamental changes towards a more democratic society do not justify the continuation of the war imposed by the armed opposition in my country. As you may imagine, the war is the main cause of the worsening health conditions of the Mozambican people. As a consequence of the war, last year more than one million Mozambicans fled the country to seek protection and security in neighbouring countries, and almost four million are internally displaced from their original areas. Apart from the war, the southern African countries and huge areas of Mozambique are facing the most severe drought of this century. As a consequence of this calamity, more than 25% of 16 million people are directly affected. The harvest of this year will fall dramatically.

Malnutrition has become one of the leading causes of morbidity and admission to hospitals. Food aid is desperately needed. We take this opportunity to make an urgent appeal to all countries to do their best, as in the past, to support our country in this emergency and dramatic situation. We have already prepared in conjunction with the United Nations agencies a report on the situation prevailing in our country in which we have included the most urgent needs to save the lives of our people. We do hope that the delegates present here as well as the representatives of different organizations and agencies will make their best efforts to respond positively to this request of Mozambique.

Effects on the environment are another consequence of the drought and of the war situation. Displacement of populations and their concentration in cities and other urban areas is provoking serious sanitation problems and destruction of forests for firewood purposes in very extensive areas around urban centres.

Mozambique is a coastal country and its geographical and strategic position in regard to the Indian Ocean justifies its concern on issues such as sea and water pollution. For the first time, the country is now a victim of one of the most catastrophic incidents. The Katina-P, a Greek oil tanker with 60 000 tons of fuel oil, suffering from a rhumb on its way from Venezuela to the United Arabic Emirates, stranded in our own national waters on Friday, 17 April 1992 and began spreading oil in Maputo Bay about 10 km north of Maputo, the capital of the country. About six days after the incident and before the tanker had been trailed out of our exclusive economic zone, more than 3000 tons of oil with a high content of sulfur had been spread over the Bay. On 26 April, about three days after trailing began, the tanker exploded and sank in our national waters about 150 km from the coast. When we left home there was no detailed information yet about the destination of the 60 000 tons of fuel and the future effects on our coast.

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The consequences of this new calamity on the economy and on the health of the population of the southern part of the country are unpredictable. Damage to our maritime fauna will be dramatic. Fishing, one of our main economic activities, playing a very significant role in the economy, is seriously affected.

The nearby population is now suffering from the first immediate consequences provoked by the oil already spread, and I will mention some of them: more than 3000 private fishermen and some companies are obliged to suspend their fishing activities while the cleaning of the waters and banks of the Bay is going on; Maputo City residents are temporary prevented from consuming seafood from the Bay; tourist and leisure activities on Maputo beaches have been forbidden.

My Government is now involved in investigations to determine the circumstances under which the crew of the tanker decided to strand in Mozambican waters and not in international waters in order to prevent this catastrophic situation for our country. This incident must be seen as one of the examples and lessons to be learned about the need for cooperation in this field and about real measures to be taken in environmental protection and safety rules on maritime navigation in the Indian Ocean.

Despite the war situation and calamities affecting our country, there have been some important achievements during the years 1990-1991. In the expanded programme on immunization and the maternal and child care programme, for example, coverage of urban areas was as high as 80%. On the tuberculosis programme, the results of short-course chemotherapy with a reduced number of defaulters are good, although we have some concerns on the increase of cases in relation to tuberculosis and HIV association.

The national AIDS programme is running in a satisfactory way. We hope that the information and education components of the programme will have a positive impact in reducing the spread of the epidemic, particularly among youths. The education and information campaigns in schools seem to be important as a way of preparing new generations and creating positive attitudes, habits and behaviour towards sexuality.

We have to recognize that adults, despite being aware of the preventive methods to prevent infection, are not changing their attitudes as expected.

By the end of 1991 about 400 cases of AIDS had been declared, corresponding to 25 cases per million people. The number of cases is doubling roughly every eight months. We are very concerned about the seriousness of the problem.

The political situation in southern Africa is being reshaped. The independence of Namibia, the successes obtained in Angola in the move towards peace, the recent events in South Africa with the irreversible destruction of the apartheid system and the possible establishment of a new, democratic and representative Government, and the peace talks in Mozambique to end the war, are elements to significantly back this statement. We are confident in a new southern Africa within less than one year, when all countries in the region will work together without any kind of barriers. We expect that South Africa will soon join the Southern African Development Co-ordination Conference and we look forward to the re-admission of South Africa in all international forums such as WHO and to discussing common problems in the field of health.

Finally, please permit me, Mr President, to take this opportunity to thank the governments, agencies and nongovernmental organizations represented in this Assembly for their generosity, both in the area of cooperation and development of programmes and in emergency and rehabilitation programmes. I would particularly like to thank the countries sharing common borders with Mozambique for their humanitarian aid to Mozambican refugees in their countries. We consider that this support, apart from humanitarian aid, is also a great contribution to the peace and reconciliation we are involved in, in our own country.

Mr VON HERTZEN (Finland):

Mr President, Mr Deputy Director-General, distinguished delegates, when we look back at the hopes and aspirations that we all had over ten years ago when health for all by the year 2000 was approved unanimously by this Assembly and we look at the health situation in the world today we may rightly ask ourselves, "Are we making any progress at all? Could we do better?" Personally I think that the answer to both questions is, "Yes".

The delegation of Finland wishes to express its gratitude to the Director-General for his excellent and comprehensive report (document A45/3) on the implementation of the Global Strategy for Health for All by the Year 2000. The report clearly shows that we have been witnessing a positive change in attitudes and some progress in certain areas of activity which are of fundamental importance for health development in the long run. The coverage of the main elements of primary health care has increased, immunization against major tropical diseases has increased, infant mortality has decreased and the interaction between health and the environment has been acknowledged in many ways.

In spite of our common endeavours towards better health and health development, it seems that we are still confronted with a health crisis. The report shows the widening gap between developed and developing

A45/VR/6 • page 8

countries. It also shows that, in particular, many of the least developed countries have made little or no progress at all. Moreover, the changed political and economic situation, particularly in Europe, has caused a crisis in some countries as far as health is concerned. Thus the international health community has experienced an increasing need to strengthen not only the short-term emergency preparedness, but also coordination and collaboration with Member States and other United Nations and international organizations, in order to be able to give help just in time to those who are most in need.

My delegation is of the opinion that WHO should strengthen its activities in these countries so as to better meet their health needs. We are naturally especially interested in cooperation with our neighbouring countries. The programmes related to the social and health sector are already ongoing. We are of the opinion that this health crisis cannot be managed only through short-term and ad hoc measures. Today we also need to develop and intensify the implementation of long-term comprehensive and horizontal health programmes. These should include health and environment in order to achieve sustainable solutions to health problems on the basis of interdependence, interaction and collaboration.

My delegation is pleased to note that WHO is now actively working on international harmonization of safety and efficacy requirements for pharmaceuticals. In the long tern, harmonization of requirements may provide savings even in administrative resources of the governments and new treatments become available to the patients without unnecessary delays.

According to our experience the formulation of a national health-for-all strategy has had a positive impact on leadership for health. As a European pioneer country for the health-for-all programme, Finland has formulated its own national health policy on health-for-all principles in the mid-eighties. Through the health-for-all strategy and its targets we have been able to keep health development high on our national agenda even today, when our country is facing its deepest economic depression since the Second World War. Indeed, we can be pleased to have developed a strong and comprehensive primary health care service system which has also proven to be economically profitable in promoting health.

The formulation of a strategy for health development at the national level has also enabled us to better ensure sustained financial resources for provision of health services. In the situation when many countries are confronted with the economic and health crisis, it is of vital importance to have a long-term strategy for health development. As to the long-term strategic work of WHO, the strategy for health for all by the year 2000 deserves our full support.

The Finnish health policy with reference to the health-for-all programme has been evaluated by a high-level expert group nominated by the WHO Regional Office for Europe. Last August, the review report was published containing both acknowledgements and criticism. It was especially important that the review group was able to analyse, in a neutral way, some difficult issues, which at the national level had been too sensitive to be thoroughly discussed. After the review, a revision of our national health-for-all programme has been prepared. We support strongly the proposal expressed by the review group that WHO should carry out similar policy reviews in other countries as well, in order for them to develop national health policies.

I wish to touch upon one of the basic principles of health-for-all, which is intersectorality. The delegation of Finland welcomes the active role of WHO in building intersectoral collaboration at global level. This is especially indicated by WHO's valuable contribution to the United Nations Conference on Environment and Development (UNCED).

The importance of environmental issues can never be overestimated. It is a necessity for mankind to adopt the principles for sustainable development. The social and health implications of sustainable development have not been seen clearly enough - this applies at least to discussions in our country. Thus the work of the WHO Commission on Health and Environment is extremely valuable. It increases the possibilities for a successful conference in Rio de Janeiro.

As regards environment and health, let me once again refer to the Chernobyl nuclear disaster six years ago. The consequences and repercussions of this accident still need to be addressed. My Government has indicated three projects in the overall United Nations plan prepared for the Chernobyl Pledging Conference held in September 1991 in New York, which it is going to finance.

Healthy nutrition is one of the most fundamental prerequisites for health, and collaboration between the agricultural and health sectors is needed at ail levels. In our country, such collaboration has consistently been constructed during the 1980s. This has resulted in a rapid change in nutritional habits, leading for example to the positive, ongoing decline in mortality from coronary heart disease.

The delegation of Finland is looking forward to increased collaboration with WHO at the global and regional level and with other United Nations organizations in order to better enhance positive and sustainable health development.

A45/VR/6 • page 9 M. PENDY BOUYIKI (Gabon):

Monsieur le Président, Monsieur le Directeur général, distingués délégués, Mesdames et Messieurs, Monsieur le Président de séance, l'occasion que m'offre ma toute première participation à une session de l'Assemblée mondiale de la Santé me permet de vous adresser au nom de la délégation gabonaise nos chaleureuses salutations. Je voudrais ensuite présenter au Président, ainsi qu'à tous les membres du bureau, nos vives félicitations pour avoir été portés à la tête de cette Quarante-Cinquième Assemblée mondiale de la Santé et amener ainsi à diriger avec brio nos débats. Je leur souhaite plein succès pour la suite de nos travaux.

En examinant l'ordre du jour de cette Quarante-Cinquième Assemblée mondiale de la Santé, nous avons relevé que, malgré leur très grande diversité, les questions que les délégués ici réunis doivent aborder en deux semaines de travaux répondent parfaitement à nos soucis constants de décideurs.

Comme vous le savez, Monsieur le Président, honorables délégués, l'année qui vient de s'achever aura été plus que les précédentes riche tant en événements politiques, sociaux et économiques qu'en défis de tout genre, difficiles à relever en raison des incertitudes qui mettent à rude épreuve la solidarité internationale. Le Gabon, mon pays, était de ceux qui ont ouvert très tôt, dès mars 1990，le cycle des conférences nationales africaines, prélude à l'engagement inéluctable de la plupart des nations africaines dans le pluralisme démocratique. Suite à ces bouleversements, la mise en oeuvre des stratégies, si elle ne s'est pas arrêtée, a tout de même tourné au ralenti. Les secteurs sociaux, dont la santé, ont été les plus touchés, mettant en évidence des insuffisances longtemps occultées.

Le département dont j'ai la charge est conscient qu'il lui faudrait trouver rapidement des solutions compatibles avec les ressources disponibles et le contexte culturel, sociopolitique et sanitaire. C'est pourquoi nous venons d'entreprendre une réflexion qui doit au bout du compte nous donner une nouvelle vision des problèmes de santé et nous conduire à la gestion rationnelle du système de santé. A l'issue de ces journées de bilan pour de nouvelles perspectives, les participants ont à nouveau réaffirmé la détermination politique du Gabon en faveur des soins de santé primaires et de l'objectif de la santé pour tous tels qu'ils ressortent de la deuxième évaluation des stratégies nationales de santé.

Nous aimerions nous attarder sur quelques-uns des points inscrits à l'ordre du jour de cette Quarante-Cinquième Assemblée mondiale de la Santé et plus particulièrement sur la mise en oeuvre de la stratégie mondiale de la santé pour tous d'ici l'an 2000, la santé de l'enfant et du nourrisson, notamment en ce qui concerne la mise en oeuvre du Code international de commercialisation des substituts du lait maternel, ainsi que sur les risques liés à la maternité. S'agissant du premier point, le Gabon, à l'instar d'autres Etats, a participé à l'exercice combien opportun de la deuxième évaluation. Celle-ci, en donnant aux responsables de la santé une nouvelle occasion d'apprécier les tendances du développement sanitaire, politique et économique et en facilitant l'obtention de renseignements sur Faccessibilité et la qualité，permet une meilleure définition des mesures les plus urgentes, débouchant sur une nouvelle approche des perspectives à moyen et à long terme.

A la lecture du document sur la santé et le développement de l'enfant (santé du nouveau-né) 一 second domaine que je voudrais aborder -, on est frappé par le fossé qui persiste depuis des années entre les pays nantis et les pays en développement. Si ce fossé n'affecte pas les premiers cités, il exacerbe malheureusement chez les seconds le manque de personnel qualifié et l'absence de logistique et de technologies adéquates dont devraient bénéficier les services de néonatalogie, et surtout il accentue la faiblesse du développement de tous les programmes susceptibles de promouvoir la santé du nouveau-né, c'est-à-dire des programmes relatifs à la nutrition, à la vaccination, à la salubrité et à la simple hygiène. Dans ce domaine toujours, mon pays, dans le but de faire aboutir notre engagement de promouvoir et appuyer Pallaitement au sein conformément à celui pris par les Chefs d'Etat et de gouvernement au Sommet mondial pour l'enfance, ainsi que la mise en oeuvre du projet des hôpitaux accueillants pour l'enfant, a demandé à toutes les sociétés et aux représentants locaux des fabricants et distributeurs de lait et aliments pour bébés : premièrement, l'arrêt des distributions gratuites et subventionnées de lait et aliments pour bébés dans les hôpitaux, maternités, centres de protection maternelle et infantile, cabinets médicaux et toutes autres structures parapubliques et privées; et deuxièmement, l'arrêt de toute publicité en faveur des laits et aliments pour bébés. Actuellement, plusieurs hôpitaux, services de santé et structures diverses de mon pays - où le taux de mères allaitantes est l'un des plus bas du continent par l'effet d'un mimétisme coupable et d'un snobisme anachronique - s'attachent activement à promouvoir la pratique de l'allaitement au sein. Afin de renforcer cette action, un séminaire-atelier des décideurs des secteurs publics, parapublics et privés est programmé depuis le 6 de ce mois, en vue d'adopter une politique nationale en matière d'allaitement au sein, un code national de commercialisation de substituts du lait maternel et un plan d'action à court et à moyen terme pour l'application de cette politique.

Toujours en faveur de la mère et l'enfant, le Gabon mène aussi des activités de maternité sans risque financées par le Fonds des Nations Unies pour la Population et exécutées par l'OMS. Réalisé dans l'optique du scénario de développement sanitaire de l'Afrique, ce projet, dont les objectifs ont été orientés en vue de

A45/VR/6 • page 10

couvrir les groupes à risque, notamment en zone rurale, s'articule autour des activités suivantes : sensibilisation de la population, des autorités locales, des organisations non gouvernementales, des adolescents et des femmes en âge de procréer à l'importance des risques liés à la maternité en général et aux grossesses précoces, ainsi qu'aux avantages de l'espacement des naissances; formation de base et formation continue des personnels des maternités et des centres de santé maternelle et infantile, des dispensaires et des cases de santé; développement de la recherche opérationnelle concernant la santé de la mère et de l'enfant; enfin, mise en place d'une infrastructure médicale adéquate.

S'agissant de la santé des femmes, thème des discussions techniques de notre Assemblée, les femmes gabonaises viennent de tenir un forum national sur la condition de la femme, condition qui a toujours suscité de nombreux débats. Les associations de femmes juristes, de femmes scientifiques et plusieurs autres associations participaient à cette réunion. Au cours de ce forum, un accent particulier a été mis sur les problèmes d'actualité tels que la condition sociale de la femme au foyer, la condition sociale de la femme seule, sans travail et chef de famille, la femme en milieu rural, rimmigration massive au Gabon dont les femmes restent les principales victimes, la violence subie par les femmes, la dégradation des moeurs, les abandons d'enfants, la planification familiale, les maladies sexuellement transmissibles et le SIDA (pour lequel les différents bailleurs de fonds se sont réunis à Libreville le 9 mars dernier afin de redynamiser le plan d'action à moyen terme de notre programme national, ainsi qu'il a été préconisé); la condition sociale de la jeune fille, la libéralisation des méthodes contraceptives devant se traduire par la vente libre des contraceptifs; la délinquance juvénile, avec l'application rigoureuse des lois en matière de protection des mineurs, ainsi que la possibilité de sanctionner plus sévèrement les adultes responsables de délits de moeurs; la condition de la femme rurale et sa participation active au développement, grâce au désenclavement des zones rurales par la réfection et Pextension du réseau routier, l'introduction de technologies nouvelles pour l'amélioration des conditions de travail de la femme rurale et un plus grand développement des infrastructures sociales parmi lesquelles l'eau, Pélectricité et les dispensaires, et grâce aussi à la révision du régime foncier en milieu rural afin de permettre à la femme de jouir de son droit d'accès à la propriété (à cela s'ajoute Paccent mis sur les programmes d'alphabétisation et particulièrement sur l'alphabétisation fonctionnelle); la condition de la femme en milieu urbain, avec le réaménagement des textes de loi reconnaissant la spécificité de la femme mère, épouse, et travailleuse, afin de tendre vers l'attribution d'une allocation de salaire unique aux femmes seules, chefs de famille et sans travail; l'ouverture d'un centre de formation aux petits métiers et la sensibilisation des femmes citadines à la vie associative, ce qui leur permettrait d'exécuter de petits projets rentables et constituerait une des solutions proposées au cours de cette réunion pour lutter contre la dégradation des moeurs; la violence, d'abord, dénoncée dans les foyers et dont on a décidé de mettre en relief les manifestations morales et matérielles dont sont victimes les veuves, la coutume tolérant que celles-ci soient spoliées d'un héritage légitime (une révision du droit à la succession ayant été proposée ensuite, et le harcèlement sexuel dans les milieux professionnels étant par ailleurs retenu comme une forme de violence que le législateur doit proscrire); la planification familiale et la contraception, avec l'abrogation de la loi interdisant la contraception au Gabon au profit d'une planification familiale systématique (la politique pronataliste du Gabon devant être fortement encouragée par des mesures incitatives, notamment les allocations familiales, la couverture sanitaire de la mère et de l'enfant); enfin, le travail de la femme, au sujet duquel, afin de permettre à celle-ci d'être intégrée à tous les niveaux du processus de développement, le forum a demandé moins de complaisance dans l'application des textes de loi garantissant le salaire minimum interprofessionnel garanti sans discrimination de sexe ainsi que dans les facilités prévues par l'Etat en faveur de la création des petites et moyennes entreprises.

Monsieur le Président, distingués délégués, ce sont là les quelques thèmes sur lesquels ma délégation a voulu se prononcer. Les autres sujets de préoccupation de l'Assemblée de la Santé ne nous laissent pas pour autant indifférents. Nous les aborderons en commission.

Mr DOUGLAS (Jamaica):

Mr President, Vice-Presidents, Deputy Director-General, distinguished representatives of Member States, ladies and gentlemen, on behalf of my delegation and the Government and people of Jamaica I am pleased to join in congratulating the President and Vice-Presidents on their electioñ to office and to be given this opportunity to address the Assembly. It is indeed a pleasure to join with representatives of the global community to examine the achievements of WHO during the past year. I must commend the Director-General on the achievements presented in his report. "Women, health and development" is a most appropriate theme for this year's Technical Discussions and it is fully supported by my delegation. Women as a group have been particularly vulnerable to the pressures of structural adjustment policies which have affected developing countries like Jamaica during the 1980s.

A45/VR/6 • page 11

Under programmes sponsored by the World Bank the intent was to put unutilized capacity to work, especially in those sectors which could produce incremental foreign exchange. Unfortunately, these policies have met with only partial success. The situation was compounded by the devastation caused by a major hurricane in 1988.

Concurrently, Jamaica has been experiencing serious rates of inflation, up to 80%, during 1991, a continuous de facto devaluation of its currency, and it has had to service a heavy burden of foreign debts, representing up to 45% of the national budget. The impact of these economic policies on the social services has been severe. The problem of the "brain drain" to the North has been exacerbated by the Ministry of Health's inability to pay competitive salaries to certain critical groups. This has particularly affected nurses, who are lured to North America for relatively higher remuneration. In addition, vital training had to be reduced and expensive structures and equipment became eroded, due to lack of funds for adequate maintenance. Other categories, such as pharmacists, turn to the private sector soon after graduation. The effects are also being seen in the health and nutrition status. A 1990 survey revealed that 7.3% of Jamaican children under three years of age had achieved less than 80% of the normal weight for their age. This has been accompanied by a decline in breast-feeding practices.

In a situation where the Jamaican Government provides over 80% of the nation's health care, the public health services suffered serious decline during the 1980s. The Ministry of Health's budget fell from 7.6% of the national budget in 1979/80 to 6.95% in 1989/90, having achieved a low of 5.69% in 1987/88.

In response to these challenges，we have been pursuing several strategies. In tandem with the Executive Board's dictum of "Leadership for health: framework for new public health action", we are embarking on far-reaching transformation strategies to enhance the health care services. A major reorganization effort is being pursued through a programme to decentralize the management of the health care delivery services. This programme includes strengthening the management structure of the country's 24 hospitals. We are divesting a number of non-medical hospital services to private operators. Additional revenue is to be generated by ensuring the efficient collection of fees for services provided in public health facilities.

The Government has recognized its responsibility in strengthening the role of nursing and midwifery in support of the strategy of health for all. Among other things, special scholarships have been provided since 1989 to encourage potential students for nursing to qualify for entry to schools of nursing. This has been very successful. We are designing public/private sector partnership schemes. An innovative partnership with the private health insurance industry is being designed in an effort to expand wider coverage for the population, including the indigent. My Ministry has stimulated and encouraged the private sector organization of Jamaica to develop a number of projects involving the private sector in health care. Non-government organizations which have not previously been involved in home care services are being encouraged to consider this as an area for investment.

Our intensive resource mobilization efforts have resulted in the realization of a number of capital development projects. These include a health services restoration project supported by the Inter-American Development Bank, a social sector development project and part of the larger human resources development programme, a population and health project, also funded by the World Bank, a health management improvement project supported by USAID, and a programme of bilateral assistance from the Italian Government. Other bilateral programmes of assistance have been supported by several governments and agencies represented at this Assembly.

Special mention must be made of the intensified support project being funded by WHO. The Jamaican health sector has also been striving to meet two major new challenges. We had our first reported case of AIDS in 1982 and up to December 1991, 333 cases had been reported. These include 31 paediatric cases with an overall mortality rate of 66%. The fight against AIDS has been integrated with the overall programme for the control of sexually transmitted diseases. High priority status has been afforded this programme within the Ministry of Health. In addition, significant private sector cooperation has been mobilized in a multisectoral approach to deal with the HIV epidemic. Measurable successes have been achieved in the areas of public education, condom distribution, training, enhanced surveillance capabilities, counselling services, a centre for rehabilitation of AIDS patients, a telephone helpline, research and screening of donated blood.

Another potential large-scale health threat to Jamaica is the regional cholera epidemic. Existing unfavourable sanitary conditions, free travel between Jamaica and affected countries, and the difficult economic situation have increased our susceptibility. The country has been put on a full cholera alert, and a national committee has been established to take all necessary steps for avoiding an outbreak or coping effectively if the need arises. This has involved improved surveillance measures, laboratory preparedness, a massive training programme for health workers, high impact public education efforts, travel advisories, intensified food inspection, monitoring water supplies, and storing adequate emergency supplies.

Multisectoral collaboration is under way to work out solutions in the area of environmental protection. Other important programme areas requiring support include mental health and health promotion. Mental

A 4 5 / V R / 6 • page 12

health laws are now being modernized, but our national mental hospital is in dire need of major upgrading. The Jamaican delegation hopes that the United Nations Conference on Environment and Development

planned for June in Rio de Janeiro will make a major contribution to solving the increasing environmental, ecological problems facing the world community. Solutions must be found to an appropriate sharing of the responsibilities among the developed and developing countries in tackling the now enormous task for conserving the resources and preventing the pollution of the environment.

Health promotion is a national priority. These is a growing need to develop and sustain programmes to deal with the epidemic of the lifestyle-related chronic diseases now among the leading causes of illness and death in our country.

Our programme on women in health and development was launched in 1980. Intersectoral collaboration, as well as wide and active community outreach are important parts of this effort. Programmes are island-wide and feature cancer and STD screening, health education, rubella immunization, family planning services, as well as income-generating schemes. We are still endeavouring to develop gender-sensitive data collection and analysis, gender-sensitive and "gender-friendly" work environments, and increased female representation at the highest decision-making levels.

In Jamaica we have reaffirmed our commitment to PHC as the main strategy in our efforts to achieve health for all by year 2000. We continue, in the face of national economic constraints, to deliver the best possible health care with the limited resources available. The emphasis on responsible care and the search for ways to ensure protection of the most vulnerable and marginal groups remain two of our major concerns. In this regard, health promotion and disease prevention continue to be foremost in our national strategies as we strive towards health for all by the year 2000.

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Dr STAMPS (Zimbabwe):

Mr President, distinguished delegates, ladies and gentlemen, friends, we live in a world of dramatic change. Indeed, it has been said with justification that the only consistent thing about the world today is its constant change. In this very fluid state, health, which requires stability to thrive, is most at stake. And it is clear, that, wherever in the world one looks, the health of our future generation, children and young adults, is challenged.

In my country malnutrition and actual starvation due to an unprecedented drought and the terrible scourge of AIDS, which now accounts for 22% of hospital deaths in children up to five years of age, have added to the burdens of tropical diseases and trauma. This has effectively wiped out the health gains of the past decade which reduced morbidity and mortality through primary health care, universal child immunization and the promotion of breast-feeding and sound nutritional knowledge. In the developed countries，trauma and substance abuse seem to be creating similarly adverse trends in the younger sector of the population. We are running out of future for our children. Those with power to change conditions in favour of equity are insensitive to the issues, or lack the political will or foresight to facilitate change and are comfortable as proxy critics for the monetary establishments while promoting democratic liberalization, preserving financial mythology as imagined by Adam Smith.

A45/VR/6 • page 14

Let us recall the ecology of the post-Adam Smith era, as regards human, rather than market, values. Life expectancy for males, was 42 years. Only one of five children survived to the age of five years. The average length of a marriage was 12 years - terminated not by divorce but by the demise of one of the partners, usually the woman. Teenage pregnancy was the rule, rather than the exception, baby dumping was commonplace and the epidemiological pattern of syphilis (for which there was no cure and no vaccine) indicates the profligate promiscuity of the era. Dickens epitomized the philosophy through the memorable words of Scrooge in "A Christmas Carol" - "If the poor are going to die of hunger or disease, they should better do it quickly and relieve the world of its excess population": or, more cynically, Jonathan Swift commenting on the potato famine in Ireland - "The Irish should eat their children: that would solve both the population and the hunger problems".

Of course, they did not. They emigrated to a Brave New World: this is just what, justifiably, the northern hemisphere fears from African regions south of Calais: the European metropolitan countries colonized Africa. Africa, they fear, will colonize Europe.

So a supplementary strategy has been devised, the logic of population control. These protagonists have hijacked the high principles of family planning; the bait for the individual is a higher standard of living, for the country a lower morbidity and economic emancipation. Our intelligent population in Zimbabwe has grasped these promises of modern contraceptive techniques - (at our recent International Trade Fair, the Zimbabwe National family Planning Council walked off with the first prize). In our country, from a low contraception use prevalence of 14% at Independence in 1980, most recent figures show that over 50% of women of childbearing age use modern contraceptive procedures and there is an unserved constituency of nearly 20% more who wish to use, but cannot gain access to, hormonal contraception. However, it seems that the promises I have referred to appear doomed to remain unfulfilled.

A modern-day Swift, Dr Maurice King, last year suggested in a thinly veiled Nietzschean proposition that, economically, African lives are not worth saving. Auberon Waugh is of the opinion that the loss of a book is more of a tragedy than the loss of a child because children can so easily be replaced. Human life has become part of the throw-away philosophy.

The philosophy of population control is based on a concept of numerical equality which we in Africa do not seem to enjoy in any other context. As a matter of fact the cost, environmentally, of one northern hemisphere child is more than one hundred times that of a sub-Saharan African child. And the logic of persuading parents to limit families so as to improve their status does not bear examination given the ecological pressures already destroying our global security.

Growth, in the economic sense, has in the northern hemisphere been almost entirely saprophytic. More investment has been disbursed in taking over existing enterprises than has been directed toward new capital creation. New investment in the leisure and entertainment industries have been the most successful in terms of monetary return.

In Africa, on the contrary, our entertainment is provided mostly at little or no cost to the audience, has a cultural purpose and welds together people too poor to buy a television set. Of course, we have not forgotten our spiritually impoverished friends in the North. Paul Simon's rehabilitation was entirely due to the "discovery" of African rhythms. And in the health field we use the medium of entertainment as an effective form of communication of health information, as opposed to the commercial pop-music market which is devoted to the promotion of promiscuity, drug dependency and other iconoclastic pursuits to benefit the proprietors of the modern media bordellos. The destructive effect on the susceptible vulnerable clientele seems to be of no consequence in the Gadarene rush to infect every youngster with the virus of self-interest and community anomy. And in the process the fourth estate, the offshore world of finance is happy to appropriate the environmental, ecological and ecumenical issues of the day. Abolition of opposition has always been a primary objective of every totalitarian tyrant. And in the pursuit of self-aggrandizement, the priests of property and the monks of money regard their rights as inviolable, while personal, human rights must be subordinate or even ignored. It is most interesting that this disregard is the very defect of which our imperfect, but sensitive governments in southern Africa are most accused. Yet refusal of our right to require that those who use our land must respect overall national needs confirms for me the words of Omar Bradley -"We have become technological giants and moral midgets".

It is high time we recognized some of the distortions which threaten future relationships. Subjective opinions which are less than adequately informed cannot help. In the CITES Forum it seems that some authorities want the African continent to become a botanical garden for the developed world, not a self-reliant community in her own right.

What we really need is a truly new world order - not an engineered buy-out of socialist sycophancies by dubiously sustainable capitalist concepts: not a takeover but a trading revolution. Do not undermine our small successes • in agricultural diversification, in mineral exploitation, and especially in the whole spectrum of health promotion. For some conditions • notably malaria and bilharziasis _ we are better than metropolitan countries at achieving a successful outcome. We have sustained our expanded programme on immunization while

A45/VR/6 • page 15

making the programme more cost-effective and have added new strategies, especially AIDS advocacy and community-based distribution of contraceptive materials. Nationwide, the annual consumption of condoms has grown from 500 000 in 1985 to 65 million this year. Yet the quality of life for our people has declined as a result of the tendency of those with economic power to "move the goal posts" with depressing regularity.

Whether this be in the management of elephants, unfair trading practices such as agricultural subsidies and protectionist quotas, or the use of HIV serology-screening to restrict inter-country travel, xenophobia is based on ignorance and a fear of new challenges - it results from the unjustified stereotyping of the African male as being socially incompetent and sexually incontinent, and the equally obnoxious concept of Arayan superiority.

We have to abolish the things which divide us and promote mutual support on the basis of a common destiny. Those countries who think that they can be quarantined from contagion (whether AIDS or intravenous drug use) need to realize that modern mobility and the human desire for freedom will frustrate any cordon sanitaire. Only uplifting the future prospects for all our children can promote a harmoniously progressive, healthy world. We need to spread God's loving kindness to defeat the hatred in mankind. Then we can say to our children "There is a bright future: tomorrow is another day".

Le Professeur RAJPHO (République démocratique populaire lao):

Monsieur le Président, Monsieur le Directeur général, honorables délégués, Mesdames et Messieurs, c'est pour moi un honneur et un privilège de pouvoir exprimer, au nom de la République démocratique populaire lao, mes vives félicitations au Président et aux membres du bureau de la Quarante-Cinquième Assemblée mondiale de la Santé pour leur brillante élection à leurs hautes fonctions. Je saisis également cette occasion pour féliciter le Directeur général de l'Organisation mondiale de la Santé, le Dr Nakajima, qui a su par sa conduite éclairée améliorer notablement la santé des peuples du monde.

Depuis 1990, le Gouvernement de la République démocratique populaire lao a instauré une nouvelle politique économique donnant une importance harmonieusement partagée aux "trois intérêts" : celui du Gouvernement, celui de la communatué et celui de l'individu. Ce dernier prime sur les deux autres, étant la base de toute motivation durable, et la santé constitue un des leviers de commande de tout progrès social et économique.

Le Ministère de la Santé a déployé, depuis Alma-Ata, de grands efforts pour améliorer son infrastructure sanitaire, qu'il s'agisse des équipements ou des ressources humaines et matérielles. Nous avons noté une évolution favorable de la couverture vaccinale des enfants, des soins aux femmes pendant la grossesse et l'accouchement, de l'approvisionnement en eau de boisson saine, et les soins essentiels ont été rapprochés du domicile et du lieu de travail des gens. Mais les progrès ne sont pas suffisants, surtout si l'on considère le temps qui nous sépare de la fin du siècle et les nombreux obstacles qui restent à éliminer : dans certaines régions de mon pays sévit encore le paludisme, la malnutrition est observée dans bien des endroits et une partie des femmes accouchent sans la présence du corps médical.

La santé ne peut pas être une question qui concerne exclusivement le Ministère de la Santé. Elle exige un intérêt et une intervention de tous les partenaires. Or, si nous voulons accélérer le rythme de notre cheminement vers l'objectif de la santé pour tous, il nous faudra exploiter notre capital humain. De nouvelles motivations et de nouvelles perspectives sont nécessaires, qui ne seront pas seulement techniques ou gestionnaires, mais aussi axées sur les valeurs et les enjeux. Il s'agit là de la responsabilité sociale vis-à-vis du bien-être de la population, car une réelle compréhension du système de valeurs qui sous-tend la philosophie des soins de santé primaires est indispensable.

Pour le Troisième Congrès national de la Santé lao qui se prépare depuis un mois, nous avons longuement recommandé de nouvelles mentalités et aptitudes du corps médical pour le service de la population. La question du "leadership" sera Гахе de toute discussion car il est nécessaire d'avoir un ••leadership" de la santé pour tous à chaque niveau du système de santé : au niveau central, au niveau communautaire et au niveau intermédiaire. Il nous faut alors un engagement total en vue du développement et de la qualité de la vie pour accomplir de nouveaux progrès. Cet engagement total s'inscrit dans un mouvement qui va des responsables politiques de haut niveau aux simples individus, dont la contribution au développement est précieuse, en passant par les bureaucrates et les technocrates disposés et aptes à formuler des plans et des programmes conformes aux stratégies fixées.

Aussi nous faut-il un "leadership" moral; celui de la santé pour tous nous convient car il a des idées larges, est ouvert à de vastes perspectives et est fermement engagé. Il est capable de tirer les gens de leur apathie et de les maintenir dans la poursuite d'objectifs qui méritent tous leurs efforts. Le développement du "leadership" est un travail de longue haleine, qui se fera par un long apprentissage sur le terrain, par des échanges d'opinions et d'idées parmi bien des succès et des échecs dans la vie professionnelle de chacun.

A45/VR/6 • page 16

A partir de là, nous devrons élaborer une stratégie de communication, qui permettra aussi de mieux faire comprendre l'importance de la santé et d'une action en faveur de la santé à tous les niveaux de la communauté : mieux connaître et évaluer pour mieux choisir et décider.

Je profite de l'occasion pour remercier l'OMS et d'autres organisations internationales qui nous ont énormément aidés dans notre mission de développement du "leadership" de la santé pour tous. La dernière évaluation des projets de gestion des soins de santé primaires dans certaines zones pilotes nous donne suffisamment de satisfaction; nous continuons à oeuvrer pour Pextension progressive de ces projets à travers tout le pays.

En terminant, je voudrais remercier le Dr Nakajima pour le soutien constant qu'il a apporté à mon pays et également le Dr Han, Directeur régional, qui s'est toujours efforcé d'aider la République démocratique populaire lao à progresser vers la réalisation de la santé pour tous.

Dr FRIEDMAN (Swaziland):

Mr President, Director-General, Deputy Director-General, honourable ministers, distinguished delegates, ladies and gentlemen. The Director-General，s report succinctly covers all the activities of the World Health Organization in relation to activities Member States have undertaken during the biennium. Pursuant to programme achievements during the 1990-1991 biennium, the Director-General has gone further and identified five areas of emphasis for the future from a programme point of view. The Swaziland delegation wishes to congratulate Dr Nakajima on this move, especially when we are at a period in time where concrete measures must be taken to accelerate the achievements of health for all.

The Kingdom of Swaziland continues to show its commitment to the global strategy for health for all. The Government's strategy to achieve this goal is to mobilize "all for health" in a comprehensive primary health care system which allows for grassroots participation and decision-making in matters related to health. To date, all communities in Swaziland have been adequately mobilized to be in a position to take responsibility for planning for their own health needs. This has been facilitated by lots of social mobilization efforts directed at community leaders (traditional, religious, etc.), community-based workers (particularly rural health motivators, or village health workers) and communities themselves. Seminars on various aspects of maternal and child health, family planning and primary health care have been conducted for parliamentarians, traditional leaders, chiefs, teachers, religious leaders, women's groups and others during the past two years.

In line with the general mobilization for health in Africa during 1992，the Government of Swaziland is currently in the preparatory stages for a general mobilization in response to the Bujumbura Appeal of September 1991. To this end, a general mobilization committee for health has been formed, with two sub-committees. One is responsible for documenting successful community health initiatives, and the other is for social mobilization activities utilizing the print and other media, seminars, visits to other communities in the country, person-to-person contact, etc. All these activities are in preparation for the International Conference on Community Health in Africa which will be the major event in the launching of the general mobilization and also beyond it. I mention this important activity of general mobilization because it is in response to a resolution adopted by African health ministers during the biennium under discussion. Our Regional Office and the Government of the People's Republic of Congo are coordinating the preparations for the International Conference and we are indeed grateful to them.

Swaziland, like other countries in the African Region and other regions, has continued to make progress towards the provision of health services during 1990 and 1991, as shown by the reduction in infant and chüd mortality and a general overall improvement in health indicators, particularly those related to child survival programmes. However, there is great concern that the current pattern of emerging disease and the current unfavourable drought situation in the African Region will reverse the achievements attained in the past two years unless resources improve to the extent that programmes are sustainable by Government, new strategies are initiated to combat new challenges and countries and the international community respond in a prompt manner to the drought situation, lilis therefore calls for the involvement of all sectors of Government, nongovernmental organizations and private voluntary organizations.

In mid-March 1992, concerned about the likely ill effects of the emerging drought, I formed a drought task force whose main function was to assess the impact of the current drought on the health of young children and pregnant and lactating mothers in particular. The task force was composed of members of the multi-sectoral National Nutrition Council, the World Health Organization Representative, UNICEF, The World Food Programme, the Save the Children Fund, the Swaziland Red Cross Society and the Swaziland Infant Nutrition Action Network. The drought task force undertook a rapid assessment of the situation at community level nationwide during this period. The results indicated that drought is countrywide, but in terms of water availability and grazing land, some areas are affected more than others. The findings also showed that, of the main diseases that have been exacerbated by the drought, malnutrition, acute respiratory infections, diarrhoea and skin diseases such as scabies were the most rampant.

A45/VR/6 • page 17

The Head of Government in Swaziland has already declared the drought to be a national disaster and has formed a ministerial committee to participate in countering the effects of this disaster. The WHO Representative in my country has already submitted on my behalf and that of the Government a proposal to WHO requesting support to the health sector during the 1992-1993 period of the drought. I trust that this proposal will receive a favourable response from WHO personnel.

Efforts at preventing the spread of HIV infection, reducing the personal and social impact of HIV infection and mobilizing and unifying national and international efforts against AIDS have continued in Swaziland in the past two years. Since implementation of the Medium Term Plan, many activities outlined have been undertaken. This includes a comprehensive review of the programme which took place in March 1991. The second resource mobilization meeting took place in September 1991 and the first local resource mobilization meeting took place in April 1992. Activities implemented successfully during 1990 and 1991 are in five of the six components of the national AIDS prevention and control programme, namely programme management, laboratory services, epidemiology, counselling and education and communication.

Implementation of activities under the clinical components is due to commence shortly. Sexually transmitted diseases, particularly gonorrhoea, syphilis and chancroid, are a public health problem. Because of the known association between sexually transmitted diseases (STD) and HIV infection, the STD/HIV/AIDS prevention and control programme is integrated. In the past two years, the Ministry of Health has worked closely with two prominent nongovernmental organizations in the national preventive programme against AIDS. The SHAPE project involves training of secondary school teachers, headmasters and representatives of the Swaziland National Association of Teachers in STD/HIV/AIDS education and prevention. On the other hand, Project Hope is mainly involved in training of traditional healers in STD/HIV/AIDS prevention and training of counsellors nation-wide. All these activities are coordinated under the national programme. The programme achievements indicated above do not mean that the programme does not experience constraints, including lack of formalized policy statements and further guidelines for the programme.

In 1986 the Swaziland Expanded Programme on Immunization set a target to achieve a child immunization rate of 80% by 1990. After achieving 83% immunization coverage in 1989, the programme set the following objectives/targets: elimination of neonatal tetanus by 1995; eradication of polio by 1995; control of measles cases by 90% by 1995; maintenance of diphtheria morbidity of zero cases by 1995; increasing overall immunization coverage in children aged under one year to 90% by 1995; increasing tetanus coverage to 80% by 1995. These are all targets set for 1995-2000.

Programme activities during 1990-1991 have included training of 130 senior and midlevel managers in the Expanded Programme on Immunization (EPI). Training of about 2000 rural health motivators and over 500 traditional healers in EPI has also been undertaken. They have in turn developed EPI songs and they mobilize and create community awareness in recognizing and reporting EPI diseases to nearby health facilities. The disease outbreak control unit continues to investigate reported EPI diseases and vaccinates contacts. They also give community health education on these diseases. The school vaccinations team continues to visit preschools and primary schools; 28 sentinel surveillance sites have been established and they report EPI target diseases weekly, even "zero cases".

The programme for the control of acute respiratory infections was initiated in 1989 in my country. The overall objective of the programme is to reduce infant and child mortality due to pneumonia using the strategy of standard case management and immunization against measles, pertussis and diphtheria. The strategy of standard case management is being achieved through training of nurses and doctors in acute respiratory infection case management. In March 1992，my country participated in the field test of the acute respiratory infection health facility survey which was organized by the acute respiratory infection programme in Geneva in collaboration with the Regional Office. Swaziland was identified as a suitable site for such a field test because a number of our health workers have already been trained to use the standard case management guidelines, which are very similar to the ones recommended by the acute respiratory infection programme of WHO. I am made to understand that the manual for a health facility survey whose questionnaires and tally sheets were field-tested in Swaziland will later be made available to national acute respiratory infection programmes by WHO as a tool for evaluation.

During October 1990, the Ministry of Health, in collaboration with the Centers for Disease Control, USA, conducted a health-seeking behaviour study which covered a number of primary health care programme areas, namely: health care utilization, diarrhoeal diseases, growth monitoring and promotion and nutrition, maternal health/family planning, childhood immunization and acute respiratory infections. The objectives of the health-seeking behaviour study included the following: to provide qualitative and quantitative data on health-seeking practices that clarified current trends in health behaviour that were unexplained by data from recent qualitative studies; and to gather information needed to set policy for the acute respiratory infection programme. The study yielded valuable information which is being used to review programme strategies, particularly directed at the client-provider relationship. For the acute respiratory infection programme, local

A 4 5 / V R / 6 • page 18

definitions of acute respiratory infection-related illness were found to correspond to the WHO acute respiratory infection classification.

The maternal health/family planning (safe motherhood) programme has been involved in a number of activities in the past two years. These include in-country training of nurse-midwives in safe motherhood clinical practices and family planning techniques and counselling skills. Seminars on safe motherhood have been conducted for community leaders (chief) and women's groups. Through the collaboration with WHO, traditional birth attendants have been identified in the country and a training curriculum for them has been developed.

In the area of communicable disease control, with the advent of HIV/AIDS, the number of cases of tuberculosis has been increasing since 1989. We have experienced a progressive increase each year. This is a problem that calls for a re-orientation of the current tuberculosis control strategies. With respect to malaria control, the programme has been doing well in the past two years. The number of reported cases during the period 1988-1989 was 5495, and in 1991 it dropped to 1295. This means an overall reduction in malaria prevalence of 76%.

The Ministry of Health attaches a lot of importance to strengthening the referral system in our country. I wish to conclude, Mr President, honourable ministers, by saying that only through the concerted efforts

of communities, government sectors, nongovernmental organizations, private voluntary organizations and bilateral and multilateral partners can we hope to address the economic and health crisis currently facing our countries, particularly on the African continent. With such a unified approach, the goal of health for all might be realized, despite the difficult circumstances we are currently facing.

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A45/VR/6 • page 20

Dr NABABSING (Mauritius):

Mr President, Director-General, Deputy Director-General, Regional Directors, excellencies, distinguished delegates. My delegation and I wish to join the other members in congratulating you, Mr President, and the Vice-Presidents on your election to office at the Forty-fifth World Health Assembly. I would also like to thank the Director-General and the Chairman of the Executive Board for their excellent reports. Since the Alma-Ata Declaration on the goal of health-for-all by the year 2000, WHO has inspired all of us to deal with challenges old and new, and has provided us with the required global leadership in international health affairs.

The Republic of Mauritius, I am proud to say, is committed to the principles of attaining better health for all, and we are confident that if we maintained the present trend of progress we will no doubt attain the targets set for the year 2000. The exercise conducted for the second evaluation of implementation of the Global Strategy for Health for All by the Year 2000 has given us the opportunity to assess our progress in achieving the health-for-all objectives. I am pleased to state, that in Mauritius all relevant health indicators for 1991 show a marked improvement in health status, with the infant mortality rate down to 18 per 1000 live births. The crude birth rate is 20.7 per 1000 population. The crude death rate is 6.6 per 1000 and life expectancy at birth is 66 years for males and 72 years for females.

I must congratulate WHO on completing successfully the task of gathering data from 151 of the 160 countries and analysing and presenting them for discussion at this Assembly. Ibis certainly gives us a picture of the global health status which very encouragingly shows improvement in many countries, specially in the industrialized and some developing ones. But alas! The prospects in the least developed countries are alarming, and this causes serious concern on our part. Unless we find ways and means to readjust our strategies collectively, I do not see how we will help to improve health status in these countries.

In Mauritius, while focusing on social justice and equity, we are reviewing all the options to deal effectively with the range of issues confronting a complex health sector. We are continuing to strengthen and harmonize our primary health care system in order to provide an integrated service at the first-level contact. We are building a comprehensive health team comprising of health professionals, the community, and other sectors with an impact on health, including the nongovernmental organizations. While economically we are gradually moving into the group of newly industrialized countries, we are facing health problems of a complex nature associated with changing life-styles, increased consumption of saturated fats, alcohol abuse, smoking and sedentary habits. Although statistically over the last decades the population has gained in the average number of years lived, current morbidity trends reflect a picture which causes concern. Considering that the major causes of mortality and morbidity are noncommunicable chronic disorders, such as diabetes, cardiovascular diseases and cancer, as well as road traffic accidents, use of illicit drugs, and sexually transmitted diseases including ATOS, the priority aim of the national health policy is to address these specific issues. A primary prevention and control programme for noncommunicable diseases has been successfully launched since 1987 and is aimed at altering the life-styles of the population. The abuse of drugs and alcohol is fast becoming a public health problem with far-reaching family, social, and economic consequences. Drug dependence and alcoholism account for 60% to 70% of daily male admissions to the only psychiatric hospital in Mauritius; 25% to 35% of admissions to the main medical and surgical wards in regional hospitals are due to alcohol-related physical problems. Firm laws were enacted by the Government in an effort to clamp down on the supply of illicit drugs, and a new anti-drug and anti-smuggling unit was set up by the Police Force to crack down on drug traffickers and users. The Government has also set up programmes through different ministries - education, social security and labour - and through nongovernmental organizations, to address the issue of demand reduction and rehabilitation. In spite of all these measures, we are noting a significant increase in the use of hard drugs and alcohol. We are therefore strengthening our substance abuse programme, and support for this would be most welcome. Mauritius is committed in its national efforts to tackle the problems of HIV infection and AIDS at several levels: all blood donors are screened for HIV infection, and emphasis is laid on education, prevention, treatment, care and counselling and research, particularly related to behavioural aspects. However, Mauritius is still in the low-prevalence group of countries; we are very conscious of the fact that the potential for increased incidence is high; hence our vigilance in surveillance and health promotional campaigns.

The special topic for Technical Discussions this year is "Women, health and development". I must congratulate WHO on such a wise choice. In Mauritius, women have played an extremely important role in the economic development of the country. When the Government embarked on the programme of diversifying the economy from an agricultural base to an industrial one, we found that two-thirds of the labour force in the industrial import/export processing zone is composed of women. Naturally, the health of women, especially workers and mothers, has been a major area of concern in all our health programmes. In view of the emerging health problems and the need to mobilize more funding for health to address these issues, we are in dialogue

A45/VR/6 • page 21

with Ш10 and other agencies to formulate a comprehensive health care strategy. One of the priorities on our agenda is to produce a master plan for the health sector, to study the distribution of health costs and the impact on individuals and families, devise ways and means of financing an ever-expanding service, and study the capacity and role of the private sector, including the setting-up of a health insurance scheme, as well as

methods to integrate health services with the community. In spite of all our good intentions and strong commitments to the cause of health development, many ot

our countries are having to face unexpected catastrophes, both natural and man-made. This often disrupts completely the implementation of planned programmes because funds ear-marked for health development have to be diverted to more pressing areas. The persistent drought in the southern African region, has become a major area of concern to all of us in the Region, and we do our best to extend all possible support to those

d i rec t ly^ f f ^ed^ ^ t o t a k e t h i s opportunity to thank the World Health Organization in Geneva and the

WHO Regional Offices in Brazzaville and in Copenhagen for their valuable support to Mauritius.

Mr PUNA (Cook Islands):

Thank you, Mr President. First of all, I bring greetings from the Prime Minister, the Government and people of the Cook Islands, which is the smallest member of this family of nations; congratulations to the President and the Vice-Presidents who have been elected to these important offices; greetings to the Director-General and his staff; and many thanks for the assistance from WHO in the development of health services in our country. Special thanks go to Dr Han, of the Western Pacific Region, and to Dr Parkinson, the WHO Representative in our little part of the world.

Now, the Cook Islands is an island country in the South Pacific, with a total population of 18 000 living on 15 islands totalling 240 square kilometres of land mass scattered over 2 million square kilometres of the South Pacific Ocean. The Government of the Cook Islands has maintained its encouragement for the development of health policies and strategies directed towards achieving high standards of health and health-care services for the population over the next 10 years.

Our current development objectives follow those stated in the National Five Year Development Plan: to enhance social and economic well-being, compatible with the culture of our people, to increase community participation in the development process and to ensure cooperation with neighbours in the Region in economic, social and other matters of mutual interest. An important step took place in 1991, indicating the progressive nature of the health development programme, when the Ministries of Health and Education were linked under one Minister - myself. This was seen as a means of enhancing the development of health promotion and health education programmes through formal education programmes for both children and adults in our society. The other important step taken in 1991 was the establishment of the National Health Board, consisting of people from the public, to oversee the nation's health system. They determine the optimum use of resources and attempt to increase efficiency within the health system. Within their mandate is the restructuring of the Ministry of Health and examining all aspects of administration, operating and maintenance procedures.

The Cook Islands over the years have made good progress in improving the health situation of the people through the primary health care approach and in collaboration with the World Health Organization and other United Nations agencies, the South Pacific Commission, Australia and our mother country and partner, New Zealand. The birth rate for 1991 was 27.0 per 1000 population, showing a slight but steady increase from 24.0 in 1986. The death rate of 7.6 per thousand remained relatively constant, but the infant mortality rate of 29.4 per 1000 live births indicated a rise from 25.8 per 1000 live births in 1990. The average life expectancy at birth was 67 for males and 72 for females.

The leading causes of morbidity in ranked order were: injuries and poisoning; Ш-defined conditions; diseases of the respiratory system; diseases of the circulatory system; diseases of the gastrointestinal system; diseases of the genitourinary system; complications of childbirth and pregnancy; infectious and parasitic diseases; and diseases of the nervous system. An epidemic of dengue haemorrhagic fever in 1991 resulted in over 700 cases and 4 deaths. Immunization coverage of children under 5 years of age was 90% and becoming progressively better. Soon, all children attending school will be required to be immunized. No cases of diphtheria, pertussis, tetanus, poliomyelitis or measles were seen. Hepatitis В vaccination commenced in 1990.

The general trend of health in the country showed a marked decrease in communicable diseases, apart from the epidemic of dengue haemorrhagic fever in 1991，which was readily contained and aborted. The increasing health problems were seen in the rising incidence of noncommunicable diseases associated with changing lifestyles such as obesity, diabetes, hypertension and alcohol-related illnesses and accidents.

The major strategies for health in the Cook Islands have been continued development of the primary health care approach with emphasis on the integration of services and involvement of the community in health

A 4 5 / V R / 6 • page 22

promotion and preventive medicine in the fields of nutrition, development of healthy lifestyles, improvement of water supplies and sanitation, housing and environmental protection, the prevention of alcohol abuse and lifestyle diseases and care of the elderly; control and eradication of communicable diseases like measles, rubella, tuberculosis, leprosy, sexually transmitted diseases and intestinal parasites - there has been no reported case of HIV or AIDS in our country, and we thank God for that; universal coverage of infants and children in the immunization, child development and school health programmes, and reduction of the infant mortality rate to 10 per 1000 live births • but our wish is for nil mortality among our babies; promotion of healthy lifestyles among the population, with particular emphasis on youth, reduction of cigarette smoking, alcohol, drinking and driving, drug abuse, and the practice of more responsible and safer sex; and on-going and appropriate training of health manpower. These on-going programmes are assisted and supported by WHO, UNFPA, UNICEF, UNDP, the South Pacific Commission, USAID, as well as New Zealand, Australia, West Germany and France, and we thank you all.

I would like to take this opportunity to express the sincere appreciation of the Government and the people of the Cook Islands for the assistance and support provided by these agencies and countries to the Cook Islands health services. We look forward to their continued collaboration and assistance in the future.

In conclusion, allow me, the smallest member of this family, to do some straight talking to our big brothers and sisters in this family of nations of ours. France, thank you very much for stopping your bomb tests in our neighbourhood for one year. Please make the halt permanent. To the rest of you big brothers and big sisters, please do not litter our front yard, the Pacific Ocean, with your rubbish, for that is unhealthy for us who live in the Pacific.

Thank you, may God bless you all.

Dr AL-FOUZAN (Kuwait) : ： (ciw^UI) 、•••…”

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Le PRESIDENT par intérim :

Je remercie l'honorable délégué du Koweït de son discours. Un point d'ordre ayant été soulevé, je prie

Dr PIEL (Legal Counsel):

Thank you, Mr President. I just wanted to say, on questions of point of order with regard to a speaker, that a point of order cannot close a statement by a speaker. Any Member State or any delegate that so wishes can request the President to accord a right of reply under Rule 59. In that circumstance, when exercising this right, a delegate should be brief and preferably make the statement at the end of the meeting - that would be at about 12h30 today. That is the only point of clarification. I would be glad to answer any further questions.

Le PRESIDENT par intérim :

Je note que le délégué de l'Iraq a demandé à exercer son droit de réponse. Je lui donnerai la parole pour ce faire à la fin de la séance. A présent, j'invite l'honorable délégué de la Namibie à venir à la tribune et je donne la parole à l'honorable délégué du Mali.

Le Dr BRIERE DE L,ISLE (Mali):

Monsieur le Président, Monsieur le Directeur général, Messieurs les Directeurs régionaux, honorables délégués, Mesdames, Messieurs, je voudrais tout d'abord, Monsieur le Président, au nom de la délégation que je conduis et en mon nom propre, adresser mes vifs remerciements au Gouvernement de la Confédération helvétique pour Phospitalité dont nous avons bénéficié dès notre arrivée dans ce beau pays. Mes félicitations s'adressent également au Président et à l'ensemble du bureau pour la confiance placée en eux par cette auguste Assemblée. Je voudrais enfin féliciter très chaleureusement le Directeur général pour le document présenté, riche en informations sur la situation sanitaire des Etats Membres.

Dans la mise en oeuvre de sa politique de santé, le Mali a appliqué le célèbre scénario de développement sanitaire en trois phases, lequel a trouvé un terrain favorable car la pyramide sanitaire coïncide parfaitement avec le découpage administratif et s'inscrit dans le cadre global de la décentralisation et de la déconcentration mises en oeuvre par le Gouvernement de mon pays. Cinq grands programmes de santé publique sont exécutés pour contribuer au succès de la santé pour tous d'ici Гап 2000. Premièrement, le programme de santé familiale, dont la mise en oeuvre est assurée par le personnel socio-sanitaire et les agents de santé communautaires formés et placés à tous les niveaux, a permis de réduire d'une manière drastique la morbidité et la mortalité de la mère et de l'enfant. Deuxièmement, le programme élargi de vaccination, en place depuis 1986, se poursuit normalement et a atteint en mars 1992 des taux très encourageants de couverture vaccinale : 93 % pour le BCG, 64 % pour une troisième dose de vaccin associé contre la diphtérie, le tétanos et la coqueluche (DTC) et de vaccin antipoliomyélitique, et 56 % pour la rougeole. Troisièmement, le programme de lutte contre le SIDA a commencé en 1987 par un plan à court terme et vise à prévenir le SIDA et à lutter contre ce syndrome au Mali. Ce plan a permis de faire le point de la situation épidémiologique et a mis en évidence une diffusion du virus dans Pensemble des communautés urbaines et rurales du pays, ainsi qu'une prédominance de rinfection à VIH-2 et une prévalence élevée chez les prostituées. D a aussi permis de sensibiliser le corps médical et les décideurs, avec pour conséquence Í,institutionnalisation du programme. Actuellement, un plan à moyen terme (1989-1993), en cours d'exécution,

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a défini les objectifs spécifiques suivants : renforcer l'organisation du programme; assurer la surveillance épidémiologique; réduire la transmission sexuelle et celle par le sang; développer et renforcer les laboratoires; accroître la prise en charge des séropositifs et des malades; prévenir la transmission de la maladie à l'enfant par la mère infectée; développer la recherche; améliorer la formation des professionnels de la santé et de l'éducation. Le programme de lutte contre le SIDA s'intègre dans les services de santé existants et fait appel à une large collaboration multisectorielle. Quatrièmement, le projet santé, population et hydraulique rurale, lequel grâce à un programme intégré de réformes institutionnelles et de politiques sectorielles et d'investissements, s'appuyant sur un prêt de la Banque mondiale et d'autres organismes internationaux, viendra en complément des efforts déployés par le Gouvernement pour améliorer la santé et le bien-être de la population et élargir l'accès des communautés rurales aux services de santé et à Геаи salubre. Ce projet comprend trois composantes : santé, population et hydraulique rurale. Cinquièmement, Pinitiative de Bamako dont l'ambition est plus vaste car, en plus du volet consistant à rendre les médicaments essentiels accessibles à tous financièrement et géographiquement, elle permettra la relance des soins de santé primaires et l'élaboration d'un véritable cadre institutionnel dans lequel les populations organisées et les collectivités locales seront de véritables partenaires de l'Etat auquel sera dévolu le rôle de régulateur.

Monsieur le Président, Monsieur le Directeur général, Messieurs les Directeurs régionaux, honorables délégués, Mesdames, Messieurs, le 26 mars 1991, au prix du sacrifice suprême de centaines de ses enfants, de femmes et d'hommes tombés sous les balles d'une répression aveugle, mon pays voyait enfin s'ouvrir devant lui la voie de la liberté et de la démocratie. Aujourd'hui, après des élections libres et pluripartites, tout est fin prêt pour l'avènement de la IIIe République. La nouvelle Constitution, adoptée souverainement par le peuple, affirme avec force le droit inaliénable de tout citoyen à la santé et à la protection sociale. Ceci engage l'Etat de droit, que les futures autorités de mon pays devront s'attacher à construire, à oeuvrer avec détermination pour que toutes et tous soient égaux devant la santé et puissent bénéficier de prestations médico-sanitaires de qualité. C'est le défi que le Mali nouveau, libre et démocratique, se lance à lui-même pour que ne soit pas vain le sacrifice de ses martyrs. Je souhaite plein succès aux travaux de la Quarante-Cinquième Assemblée mondiale de la Santé.

Dr IYAMBO (Namibia):

Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, allow me to commence my remarks by congratulating the President, and the distinguished members of his bureau on their election to guide and lead the deliberations of this Forty-fifth World Health Assembly. I have no doubt that under the skilled and expert guidance of the President this Assembly will ably address itself to the work at hand and conclude its deliberations in a timely and fruitful manner.

I would also like, on behalf of my delegation and on my own behalf, to commend the Director-General and the Executive Board for their comprehensive and clear reports that have been presented at this Assembly. In debating the reports of both the Director-General and the Executive Board, we were requested amongst other issues to give special attention to the theme, "Leadership for Health: Framework for New Public Health Action". This comes against a background where a call for new public health action was made in September 1991 in Saitama, Japan, at a Public Health Summit organized by WHO and the Saitama Prefectoral Government, in Japan. In the Saitama Declaration drawn up at the Summit, the call for new public health action addresses itself to key important areas, amongst which the following are of priority importance to Namibia: education and training of health personnel; life-style and the environment; integrated approach to health, the environment and socioeconomic development; solidarity in development; public involvement in the dynamics of development; ethics and equity in health services and development; the role of women; appropriate technology; information and communication; collaboration with WHO. It is important to emphasize that amongst other issues the Summit reaffirmed commitment to the goal of health for all, and the primary health care approach as the strategy for attaining it. This we find highly commendable as Namibia remains unwavering in its commitment to the goal of health for all, through the primary health care approach.

In the field of education and training of health personnel, Namibia has developed a human resources for health development programme, which is currently in the early phases of implementation. The programme incorporates pre-service and in-service training for health professionals and subprofessionals, with a view to attaining self-sufficiency in human resources for health in the medium and long term. The programme's in-service component also addresses itself to promoting and strengthening leadership and managerial skills for health workers in leadership positions.

Under life-style and the environment, emphasis is being given to health education, the provision of safe water, and safe waste disposal facilities. The biggest potential health problem we face, during the current severe drought facing Africa is the possible outbreak of diarrhoeal diseases, particularly cholera and the

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dysenteries. In anticipation of this, my Ministry is now mobilizing and appealing for resources to boost the environmental sanitation programme and the cholera preparedness campaign in Namibia.

The integrated approach to health and socioeconomic development is fully recognized by my Government, and indeed our President, His Excellency Dr Sam Nujoma, addressing a national workshop on health, drew attention to this fact and declared that the health sector in Namibia is accorded the same priority status as those other sectors that are involved directly in economic development activities. On solidarity and development, and public involvement in the dynamics of development, my Ministry recently drew up and launched Namibia's guidelines for implementing primary health care and community-based health care. As a matter of fact, these guidelines were launched by none other than our Head of State at a ceremony also attended by the Regional Director for Africa, Dr Monekosso, on the invitation of our President. The guidelines spell out how individuals and communities will be involved in the choice of health priorities and in developing health programmes, as well as in aspects of management, monitoring and evaluation.

Ethics and equality in health have been a prime concern for us in Namibia ever since our new country achieved independence. The past year saw the construction of clinics and health centres in previously unserviced areas, as well as the refurbishing and reconstruction of many which had been devastated during the war of liberation. The provision of facilities to improve access and equity remains an ongoing process until the remotest and unreached have access to services.

Activities and initiatives to better the health of women and encourage them to play meaningful roles in socioeconomic developmental activities are also receiving priority attention. To this end my Ministry drew up a safe motherhood programme with well-defined strategies of improving maternal and child health services including family spacing. A national safe motherhood conference was held in Windhoek from 26 to 28 November 1991. Again to emphasize Namibia's commitment to improving the health of mothers and children. This conference was inaugurated by our Head of State. Other programmes to improve the health of children - the information and education programme, the expanded programme on immunization, the control of the diarrhoeal disease programme, and the acute respiratory infection programme - also continue to gather momentum. The use of appropriate technology is being promoted in the water and sanitation programme, as also is the use of essential drugs. We have just completed the compilation of our essential drug list, and the essential drugs programme will be implemented shortly in collaboration with international project advisors. Information, education and communication is another programme to which we are giving priority emphasis, generally to promote healthy life-styles and prevent transmissible diseases, but specifically with special emphasis on the prevention and control of AIDS. With the incidence of this dreadful scourge on the increase, Namibia has drawn up a national AIDS prevention and control programme with priority emphasis on information and education for the public, amongst many other activities. A successful resource mobilization meeting for the programme's medium term plan was held in Windhoek on 24 February 1992.

Before concluding, it is imperative that I pay tribute to WHO for the sound collaboration in health programme development and the technical support we receive from the Organization. I would like to register my deep appreciation to the Director-General, Dr Hiroshi Nakajima, for the support headquarters consistently renders Namibia, for instance the inputs from programmes on the Strengthening of Health Services, Malaria Control, Emergency Relief, and Health Education, as well as the Global Programme on AIDS, just to mention a few. In the same vein, I would like to commend most sincerely the Regional Director for Africa, Dr Monekosso, and his Regional Office for the invaluable technical assistance and support they are rendering Namibia, especially at this stage when we are working to put in place a health system based on primary health care, and developing and implementing health-for-all strategies.

In conclusion, my remarks would be incomplete without specific reference to the severe drought the countries in southern Africa are facing this year. My own country, Namibia, happens to be one of those hardest hit by the current drought, and I do not have to reiterate the obvious negative effects the drought is going to have on health programme development in our young country. In the face of the severe current drought we have made passionate appeals for assistance. It is my fervent hope that the international community, including all countries represented here, international and bilateral agencies will rise to the occasion and assist us with resources to pull through this unfortunate difficult period that is not of our own making. It is increasingly becoming evident that our nations are so interdependent that problems in one part of the world cannot be ignored and left to those countries affected to find solutions. In truth, our world is a global village and whatever happens in one corner of that village should be of concern to all of us, behoving us to come together and act, to seek solutions to whatever problems that arise and threaten the peace and security of our peoples. I would therefore like to end my remarks by requesting all countries and agencies represented at this Assembly to be magnanimous and generous when they respond to the appeals for drought assistance that are forthcoming, not only from Namibia, but from all the countries in Africa affected by this severe current disaster of unprecedented magnitude.

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M. SOULEYMANE (Niger):

Monsieur le Président, Monsieur le Directeur général, Messieurs les Directeurs régionaux, honorables et distingués délégués, la délégation du Niger est heureuse et honorée de prendre part à la Quarante-Cinquième Assemblée mondiale de la Santé qui tient ses assises à Genève, ville prestigieuse et accueillante de la Suisse. Permettez-moi, Monsieur le Président, de m'acquitter d'un devoir, celui d'adresser à cette auguste Assemblée les salutations fraternelles du peuple nigérien et du Gouvernement de transition, mis en place en novembre 1991. Je voudrais aussi saisir cette occasion pour féliciter très chaleureusement le Président et les Vice-Présidents de leur brillante élection et leur souhaiter plein succès dans la conduite de la lourde et délicate tâche qui leur est confiée. Je voudrais également m'associer aux orateurs qui m'ont précédé pour féliciter très vivement le Dr Hiroshi Nakajima, Directeur général de POMS, pour la qualité, la clarté et la concision de son rapport qui fait largement le point de la situation sanitaire dans le monde. Ma délégation appuie fortement les efforts menés par notre Organisation pour améliorer la santé des populations de nos pays malgré une crise économique mondiale qui s'est aggravée.

Monsieur le Président, je voudrais, avec votre permission, faire un bref résumé de la situation socio-sanitaire de mon pays. Le Niger, pays sahélien enclavé, occupe une superficie de 1 267 000 km2 et compte 8,2 millions d'habitants, dont 45 % ont moins de 15 ans. La situation socio-sanitaire est encore dominée par les maladies épidémio-endémiques suivantes. Tout d'abord, le paludisme, grave maladie de santé publique, qui continue d'être l'une des principales causes de mortalité et de morbidité au sein de la population. En 1991, les formations sanitaires du pays ont enregistré 603 272 cas, avec une mortalité moyenne de 13,92 % pour les groupes d'âge de 0 à 15 ans. Plasmodium falciparum’ l'agent étiologique principal de cette maladie, est de plus en plus résistant aux antipaludéens classiques, ce qui rend difficile la chimiothérapie à la cWoroquine. Viennent ensuite les maladies diarrhéiques qui occupent le second rang des pathologies les plus fréquemment rencontrées dans les services de santé. Elles sont dues en grande partie au manque d'eau saine, d'hygiène et d'éducation sanitaire. En 1991, les formations sanitaires ont notifié 320 259 cas. Après dix ans d'accalmie, le choléra a fait sa réapparition au cours des années 90, provoquant des épidémies d'importance variée. En 1991, 367 décès ont été enregistrés sur les 3233 cas de choléra survenus au cours de l'épidémie, soit un taux de létalité de 11,35 %. Ce taux, trop élevé, traduit les difficultés que posent la mise en place d'un système fiable de surveillance épidémiologique et la prise en charge rapide des cas. La faiblesse de la couverture sanitaire (32 %) est également un frein. Cela vaut aussi pour les autres maladies. Occupant le troisième rang, la méningite cérébrospinale présente des poussées épidémiques pratiquement chaque année depuis 1986. Cette année encore, l'épidémie a fortement sévi, provoquant 8350 cas dont 937 décès, soit un taux de létalité de 11,2 %. Viennent ensuite la rougeole, ainsi que d'autres maladies infantiles, telles que la poliomyélite, la coqueluche, le tétanos et la diphtérie, qui demeurent des problèmes de santé publique malgré le lancement, en 1987, du programme élargi de vaccination. En 1991，on a enregistré 74 357 cas de rougeole, dont 1808 décès, soit un taux moyen de létalité de 2,4 %. Compte tenu de la gravité de la situation épidémio-endémique, le Gouvernement de transition, sous le haut patronage du Premier Ministre, a lancé le 7 avril 1992, date de la Journée mondiale de la Santé, une campagne visant à renforcer le programme élargi de vaccination en vue d'accroître rapidement et de manière significative le taux de couverture vaccinale pour les six principales maladies cibles du programme. Un objectif moyen de 55 % a été fixé pour l'année 1992. Vient ensuite le SIDA, qui occupe le cinquième rang. Cette pandémie du siècle qui menace l'humanité entière n'a pas épargné mon pays. Il est utile de noter que le nombre cumulé de cas de SIDA, de mars 1987 au 31 décembre 1991, est actuellement de 505 cas dont 170 dépistés en 1991. Enfin, citons l'onchocercose qui n'est plus un problème majeur de santé publique au Niger. L'incidence annuelle est presque nulle et un plan de dévolution est en cours d'exécution.

Telle est, très succinctement présentée, la situation sanitaire qui a caractérisé mon pays en 1991. Cette situation reste préoccupante malgré les multiples efforts nationaux déployés et l'appui appréciable fourni au titre de la coopération bilatérale et multilatérale. Je voudrais d'ailleurs saisir cette occasion pour remercier les organisations internationales, l'OMS, le PNIJD, le FNUAP, PUNICEF, les organisations bilatérales et multilatérales, la Commission des Communautés européennes, Г AID des Etats-Unis d'Amérique, la France, la Belgique, le Danemark, Г Allemagne et la Chine, ainsi que les organisations non gouvernementales, du concours précieux qu'ils ne cessent d'apporter à mon pays dans la lutte contre la pauvreté et la maladie. C'est donc forte de l'expérience acquise dans la collaboration avec ces différents partenaires que ma délégation salue l'initiative du Conseil exécutif et du Directeur général de l'OMS d'insister au cours de cette session sur le thème "leadership" de la santé : cadre d'une nouvelle action de santé publique. En effet, malgré une situation économique difficile, mon pays croit plus que jamais à la nécessité d'une coopération internationale juste, efficace et pertinente. Huit années seulement nous séparent de l'échéance de la santé pour tous d'ici l'an 2000, et beaucoup reste encore à faire avant d'atteindre l'objectif que nous nous sommes souverainement fixé il y a douze ans. Aussi est-il temps, et grand temps, que notre Organisation définisse le cadre adéquat d'une nouvelle

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action de santé susceptible de redonner espoir à toute Phumanité. Cette nouvelle action doit, plus que jamais, être placée sous le signe de la collaboration intersectorielle; en particulier, la relation entre l'environnement et l'approvisionnement en eau potable doit faire l'objet d'une attention plus soutenue. A cet effet, il sera peut-être nécessaire de concevoir et d'exécuter des programmes d'action communs et d'ouvrir les réunions de notre Organisation aux décideux de ces deux secteurs. Les gouvernements et notre Organisation devront jouer un rôle important à ce titre. La nouvelle action de santé devra aussi permettre de poursuivre les programmes engagés dans les autres domaines, notamment l'amélioration de la couverture sanitaire et la lutte contre les maladies. Vive la coopération internationale ！ Vive l'Organisation mondiale de la Santé ！

Mr VAIMILI (Samoa):

Mr President, Vice-Presidents, Director-General, Deputy Director-General, honourable ministers and delegates to the World Health Assembly, Members of the Executive Board, excellencies, ladies and gentlemen, first and foremost allow me on behalf of my Government and the people of Western Samoa to extend to you all warm greetings, peace and goodwill and best wishes for a successful World Health Assembly. A special thanks to our Director-General, Dr Nakajima, our Regional Director, Dr Han, and all other countries and organizations that assist and help our country in health. I happily join previous speakers in their congratulations to the President and support on his election to preside over this Forty-fifth World Health Assembly, including his able body of Vice-Presidents and Chairmen of Committees and their officers. Your task is difficult, serious and important at this time of complex challenges and uncertainties in our changing world of situations today. Please feel assured and confident that our fullest support shall always be ready at your call in order to preserve and sustain the time-honoured noble traditions of WHO for healthy, friendly, open, responsible and constructive deliberations.

This is my first attendance to participate in this august Assembly. My experience and observations continue to affirm those noble traditions I have just referred to, in a very impressive way. I pray the same healthy atmosphere of friendship, love and peace would soon prevail and overcome the overwhelming variety and number of existing situations facing our world today. This is causing so much ill-health, suffering and economic damage. I am not averse to say I am basically a business man with only a basic understanding of health but I know that the key to make all these situations work is money. Money is that universal element which bothers and rules us all, pervading the entire spectrum of our health for all by the year two thousand. Dr Nakajima, the Director-General, I wish to remain positive and optimistic that, by the end of this last decade of the century, solutions to most if not all of our world situations would be found and established. I know the task is enormous but let us be positive and remain equal to the task.

In February 1990 and December of last year, two devastating cyclones struck Western Samoa leaving behind a trail of devastation unseen and unheard of for a hundred years or more. International relief and rehabilitation assistance and support was quick and immediate. In both hurricanes, loss of life was relatively low. Epidemics or disease outbreaks were avoided and did not occur. But the devastation to the forests, coconut, banana and breadfruit plantations and crops was widespread and they were almost a total ruin. Basic infrastructures, housing and buildings were severely damaged or destroyed. Bird and wildlife in the forests, coral life in the reefs and lagoons sustained unestimated loss and destruction. Although their lives were disrupted, our people did not panic. They were thoughtful. After having suffered one furious hurricane and facing a second more devastating one less than a year apart they judged and knew how to protect and secure their survival during the fury of the cyclones. And so it is today, some five months later, much of the rehabilitation of basic infrastructures remains to be completed, in cooperation with excellent regional and international assistance and support, before full services are restored to normal. Our people were severely shaken and somewhat at the end of their wits during and in the aftermath of the cyclone disasters. I am happy to state and report their health and well-being are substantially restored. While it may take some time to turn around our fragile economy, and our economic woes continue at unprecedented levels and pressures, our people will remain our most valuable assets. Our traditional culture of peaceful coexistence and goodwill, love and collective hard work still prevails. Natural disasters we may manage, but we pray and hope we will never be at the receiving end of man-made disasters and accidents that are not of our own making or decisions. The environment, economy and development - as declared in Omiya City, Saitama, Japan, last year - are of vital concern in all health systems and services and deserve greater and more serious attention by the health sector.

I am pleased to report that the health status of the Samoan people is protected and safeguarded by the most effective means possible within our available scarce resources. I will spare you the details of activities of the entire spectrum of health programmes in progress. Recent evaluation of the expanded programme on immunization vaccination programme places its effectiveness at just over 80%. There has been no reported or treated case of poliomyelitis for over ten years. Infant mortality rates lie between 20 and 30 per 1000 live births. Maternity mortality rates remain low and life expectancy is in the low to middle 60s. We have

A 4 5 / V R / 6 • page 29

reported one case of AIDS who returned from overseas in a terminal stage of the disease and succumbed soon afterwards, over one year ago. So far, in the limited number of blood tests done, no positive HIV infection has been detected. However, we do not remain complacent over this situation. All our efforts continue to intensify activities and messages of awareness and health education in the prevention and control of this dreaded disease. Since the cyclone disasters - particularly in December last year, with four days of constant bashing by high velocity winds - the impression gained is that a greater number of malnourished children are seen at hospital clinics. Renewed attention is being focused on this problem. Ironically, at the other end of the scale, obesity and associated life-style diseases are gaining prominence as major health problems. They are quietly replacing infectious diseases of the pre-antibiotic era. Tuberculosis and leprosy would appear to be under control but are not yet sufficiently and effectively stamped out. They remain the defiant and smouldering diseases of old. Intensified activities in health promotion and disease prevention by using primary health care correctly is expected to contain them fully.

Right now, international and national environmental consciousness is high. Our Pacific Island nations and Member States truly appreciate this mood and trust this awareness will last and continue and become a permanent habit and health behaviour in all of us. The sea level rise in the next century is a problem of huge dimension and implications. I believe the scientists and professors may not know for certain what and where that level will be. We are however very certain our volcanic island states and atolls of coral foundation may well sink and be drowned. Lasting solutions to the environmental deterioration from the impacts of man-made projects that ruin and throw our very complex ecosystem out of balance to man's disadvantage should have been enforced internationally long ago.

Serious environmental problems and issues are touching us now and will linger and remain a real threat to life on this planet and most of all to our goal of health for all by the year two thousand. Soifua ma ia Manuia.

Le Dr SHEHU (Albanie)1 :

Monsieur le Président, Monsieur le Directeur général, Mesdames, Messieurs, voilà qu'après environ 50 ans d'occupation communiste l'Albanie entre dans une ère nouvelle, celle de la démocratie. Cette démocratie survient en pleine crise économique et sociale, mais le peuple albanais qui, le 22 mars, a pu exprimer sa volonté et donner la preuve de sa maturité, trouvera le courage de faire face à cette situation plus que difficile, en appuyant de toutes ses forces l'application du programme du premier Gouvernement démocratique albanais pour passer à l'économie de marché libre, pour consolider la démocratie.

La situation sanitaire, dans le contexte de la crise socio-économique en général, est loin d'être satisfaisante. Il est vrai que, pendant la dernière décennie, suivant les orientations de l'OMS, une certaine priorité a été accordée dans le secteur de la santé publique au développement du système des soins primaires. Ses unités ont été construites même dans les villages les plus reculés. Mais le système s'est avéré inefficace à cause de la qualification insuffisante du personnel et de la modicité des ressources financières dont il disposait. Sous l'ancien régime communiste, les principales dépenses pour la santé allaient à la construction de quelques services hospitaliers de pointe uniquement dans un but de propagande, lesquels étaient de faible utilité publique et servaient uniquement à l'élite de la population.

Dans la période actuelle de transition en Albanie, la santé publique, complètement détruite, ne vit que grâce aux aides humanitaires aimablement offertes par divers Etats et organisations. Pour la sortir de cet état catastrophique, nous avons programmé une action à court terme qui vise à établir un niveau de base dans le domaine de la santé. Pour réussir dans cette action importante, nous comptons sur les aides humanitaires, que nous souhaitons recevoir pendant un certain temps encore. Nous avons des besoins urgents en médicaments, nourriture, matériel sanitaire, équipements, réactifs, etc.

En même temps, nous avons programmé une autre action à long terme (déjà entreprise), qui vise la réforme complète du système sanitaire. La réforme dans le domaine de la santé et l'amélioration de la direction, de la gestion et de l'organisation vont nous permettre d'atteindre les objectifs fixés par l'OMS dans sa stratégie de la santé pour tous en l'an 2000.

Dans ce cadre, nous avons commencé à restructurer le Ministère de la Santé pour le rendre plus opérationnel et plus efficace. Après étude de différentes expériences positives d'autres pays et compte tenu de nos conditions spécifiques, la restructuration du Ministère a abouti à la création de trois départements, dont le Département général de la Santé publique qui dirige l'organisation d'un système moderne des soins primaires. Il comprend des secteurs importants comme celui de la prévention, de Phygiène, de l'éducation pour la santé,

1 Le texte qui suit a été remis par la délégation de l'Albanie pour insertion dans le compte rendu, conformément à la résolution WHA20.2.

A 4 5 / V R / 6 • page 30

de la santé maternelle et infantile, etc. Cette restructuration nous aidera à mieux appliquer les recommandations formulées par POMS dans la stratégie de la santé pour tous.

Nous avons aussi programmé une restructuration de la santé en périphérie qui vise la construction de six ou sept hôpitaux régionaux modernes, la suppression des hôpitaux ruraux inefficaces et la réduction de l'activité des hôpitaux de district, qui vont assurer principalement les services d'urgence.

Les priorités actuelles de la santé seront l'organisation du système des soins primaires et la baisse de la mortalité infantile, de la mortalité des enfants de moins de cinq ans et de la mortalité maternelle, qui atteignent actuellement les niveaux les plus élevés de notre continent.

Pour projeter cette réforme ambitieuse, nous avons eu jusqu'à présent l'aimable assistance technique de l'OMS par l'intermédiaire de son représentant permanent auprès de notre Ministère, des spécialistes envoyés par le Gouvernement italien et d'une équipe de la Banque mondiale qui nous a fait bénéficier de l'expérience qu'elle a acquise dans différents pays de l'Est. Nous profitons de cette occasion pour remercier ces organismes de l'aide intellectuelle qu'ils nous ont offerte pendant rétablissement des programmes.

En conclusion, je voudrais souligner une fois de plus notre engagement irréversible dans la voie de la réforme du système de santé. Dans le cadre des changements démocratiques radicaux survenus dans notre pays, nous souhaitons construire un système sanitaire moderne, selon les modèles les plus avancés et les plus démocratiques. Pour réussir dans cette entreprise ardue, nous comptons sur l'aide technique et financière des organismes internationaux et de divers Etats démocratiques. Ce soutien nous est indispensable pour sortir la santé publique de l'état catastrophique où elle se trouve en cette période de transition.

Je tiens également à assurer les personnalités ici présentes de la gratitude du peuple albanais pour le soutien international apporté pendant cette difficile période de grands changements qu'il est en train de vivre.

Le PRESIDENT par intérim :

Je voudrais maintenant inviter à présent l'honorable délégué de l'Iraq à exercer brièvement son droit de réponse depuis son siège.

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Le PRESIDENT par intérim :

Je vous remercie beaucoup de votre intervention. Nous sommes à présent parvenus à la fin de notre séance et, avant de la lever, je voudrais rappeler que nous allons nous retrouver en séance plénière dans cette même salle cet après-midi à 14 h 30. Nous examinerons le point 11 de l'ordre du jour qui concerne l'admission de nouveaux Membres et Membres associés. La séance est levée et je vous souhaite bon appétit.

The meeting rose at 12h30. La séance est levée à 12h30.