世界卫生状况英文报告(2)

reproductive  age are due to complications of pregnancy and delivery. Half a million  women die every year from conditions which are easily preventable.

　　Health of the elderly

　　The increase in the number of old people in the world will be one of the most profound forces affecting health and social services in the next century. Overall, the world s population has been growing at an annual rate of 1.7% during the period 1990-1995 - but the population aged over 65 is increasing by some 2.7% annually. Of a world total of 355 million people over 65 in 1993, more than 200 million are in the developing world, where they make up 4.6% of the population, with more than 150 million in  developed countries, where the proportion is 12.6%. Although Europe,  Japan and the USA currently have the 'oldest' populations, the most  rapid changes are being seen in the developing world, with predicted  increases in some countries of up to 400% in people aged over 65  during the next 30 years.

　　Alongside the increase in the number of people over age 65, there will  also be a dramatic rise in the numbers of 'old old' - people over 80. In  1993 they constituted 22% of those over 65 in developed countries and  12% in the developing world. The world elderly support ratio (the  number of people over 65 years compared to those aged 20-64) in 1990  was 12 elderly to every 100 people of working age. It is estimated  that the figure will be 12.8 in the year 2000 and 13.2 in 2010. In other  words, while population increase during1990-2000 is estimated to be  17%, the increase in the number of elderly is likely to be 30%.

　　One of the most difficult questions for health planners and politicians trying to allocate funds, as well as for the community and individuals themselves, is whether increased life expectancy means more health  or simply more years of sickness. This is an area that is greatly  underresearched, yet the question is assuming ever greater importance.

　　Two of the most pressing problems in the future will be the provision of care for people with dementia and those needing joint replacements for arthritic diseases. WHO estimates that there are 165 million people in the world with rheumatoid arthritis. The long-term care of the frail elderly is becoming one of the most debated medical and political issues in many developed countries, and the developing world too will soon have to  wrestlewith it. If people are not to be left destitute and uncared for at the end of their lives, more attention must be given to social mechanisms for the support of the elderly and the means to fund them.

　　General health issues

　　Although in the past 10 years there has been a global trend towards the democratization of political systems, the much anticipated 'peace dividend' has failed to materialize. Poverty has continued, and will continue, to be a major obstacle to health development. The number of poor people has increased substantially, both in the developing world and among underprivileged groups and communities within developed as well as developing countries. During the second half of the 1980s, the number of people in the world living in extreme poverty increased, and was estimated at over 1.1 billion in 1990 - more than one-fifth of humanity.

　　The changing demographic picture across the world, together with the  rapid shift towards urbanization, will have profound implications for  the delivery of health services. The unplanned and often chaotic growth  of megacities in the developing world will pose particular challenges,  as poor sanitation and housing encourage the spread of infectious diseases.

　　Against any optimism about the global economy throughout the remainder of this century and beyond should be set a number of major uncertainties. There has been a disproportionate flow of resources from the developing to the developed world - poor countries paying money to rich ones - because of debt servicing and repayment and as a consequence of prices for raw materials that favour the latter at the expense of the former. Structural adjustment policies aimed at improving the economic performance of poor countries have in many cases made the situation worse. The words of Robert McNamara, spoken in 1980 when he was President of the World Bank, still hold true: 'The pursuit of growth and financial adjustment without a reasonable concern for equity is ultimately socially destabilizing'.

　　A further worrying global trend is growing unemployment, especially in developing countries without social security arrangements to cushion those out of work. Long-term unemployment is creating a new class of 'untouchables' - by excluding a large group of people from the mainstream of development and society. The unemployed are a potent reminder of the dangers of assuming that the general prosperity of a country will trickle down to all its members.

　　There is also considerable concern about the adverse health effects of continuing environmental degradation, pollution and the uncontrolled dumping of chemical wastes, diminishing natural resources, depletion of the ozone layer and predicted global climate changes.

　　Social mores are also undergoing profound changes, with a move towards shorter marriages and more divorces in many countries, leading to family breakdowns which have repercussions for individuals and for social services that may be called on to provide help for children and single parents.

　　Beyond any considerations for improving the health of the world must be the recognition that the growing world population will strain to the limit the ability of social, political, environmental and health infrastructures to cope. Health infrastructure - buildings and equipment, the staff, the drugs, the vehicles - is central to good health care. Services must be integrated, cost-effective and provided as close as possible to the people who need them.

　　With health resources unlikely to be greatly increased but with ever growing demands for services, because of expanding populations and the advances of science which make more conditions treatable, the debate about the rationing of health care, with the attendant ethical problems, is likely to become intense. Hard choices will have to be made - and greatly enhanced mechanisms found for listening to the voice of the health consume

　　WHO's contributions to world health

　　Within the framework of the organization s constitution and the guidance given in the periodic general programmes of work, all WHO activities are geared to respond to the priority problems of the age groups referred to in this summary. The full extent of WHO's work at national, regional and global levels cannot be reflected here, but examples are given of different types of action.

　　Child and adolescent health

　　WHO encourages self-reliance of countries in conducting immunization through basic health services. It cooperates with UNICEF in its initiative  of supplying vaccines to over 100 countries. Major priorities are to at least sustain the accomplishments of previous years and to continue to strive for achievement of the 1992 World Summit for Children goal of immunization against the six vaccine-preventable diseases (diphtheria, pertussis, tetanus, measles, poliomyelitis, tuberculosis).

　　In an effort to make the best use of limited resources to eliminate neonatal tetanus, WHO has given priority to countries that account for 80% of total cases and have an estimated mortality of 5 or more per 1 000 live births. WHO initiated a series of measures to arrest the spread of diphtheria in eastern Europe, including the formulation of a plan of action and the establishment of a European task force. In 1993 progress towards the poliomyelitis eradication goal was heartening. Efforts are being made to develop a more heat-stable poliovirus vaccine that can be delivered with a less rigorously maintained cold chain. Large donations for poliomyelitis eradication were coordinated with different organizations. In 1994 the region of the Americas committed itself to eliminating measles by the year 2000, and incidence is now at the lowest level ever. If the momentum is sustained the Americas may well lead the way towards global elimination of this major killer of children.

　　By the end of 1994 virtually all developing countries had implemented plans of action against diarrhoeal diseases in children. Nearly 42% of health staff in the countries had been trained in supervisory skills using materials developed by WHO, and almost 30% of doctors and other health workers had been trained in diarrhoea case management, many of them in the more than 420 diarrhoea training units established in over 90 countries. It is estimated that nearly 85% of the population of the countries had access to oral rehydration salts at the end of 1994.

　　Particular emphasis is given to training in the management of acute respiratory infections WHO supports courses for workers in first-level health facilities and referral hospitals on standard case management, and distributes training and technical materials. More than 190 000 health managers, doctors, nurses and community health workers in over 60 countries have been trained so far. WHO is involved in numerous studies on acute respiratory infections in Africa, Asia and Latin America.

　　Activities for better nutrition are promoted in 62 countries, mostly in collaboration with FAO and UNICEF. A global database on child growth was established and more than 90 countries are receiving technical and financial support to give effect to the International Code of Marketing of Breast

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