~16=

Demonstration Areas, Environmental Sanitation, Health Education
of the Public, and Nursing. Campaigns against Communicable
Diseases will be stimulated with particular reference to Mala-
ria, Tuberculosis, Venereal Disease, and other communicable
diseases. The World Health Organization is interested in the
general promotion of health by offering assistance in Maternal
and Child Health, Nutrition, Mental Health, Social and Occupa-
tional Care. Professional and Technical Education will be exe
panded by giving assistance to Educational Institutes and Train-
ing Courses through Fellowships and Exchange of Scientific In-
formation. The World Health Organization plans to arrange courses,
seminars and study groups, to promote conferences and to subsi-
dize institutes training medical and related personnel. Funds
will also be utilized to purchase medical supplies connected
with the technical assistance programs.

II. REORGANIZATION OF INTERNATIONAL PUBLIC HEALTH IN THE
AMERICAS

1. Problems Facing the XII Pan American Sanitary Conference
(Caracas 1917)

At the XII Pan American Sanitary Conference held in Caracas,
Venezuela,in January 197, Dr. Hugh S. Cumming called attention,
in his Report, to the need fa:

(1) Reorganization of the Bureau.

(2) Adequate financing of the Bureay.

(3) Appropriate headquarters space.

(4) Development of an inter-American professional staff.

(5) Working out suitable relations with the World Health
Organization.

(6) Avoiding lack of representation of Member Governments
at Pan American Sanitary Conferences, because of
political differences with the host Governmnt.

(7) Establishing a salary for the Director of the Bureau
and fixing his term of office.

The Report referred to the wrk of the Bureau in 196 related
to the coordination of health activities along the Mexico-United
States Border, to the study and control of specific diseases such
as plague, typhus, onchocerciasis and venereal diseases, toa
Special project in nutrition for Central America and Panama, to
the sanitation of the Pan American Highway, to professional sanitary
a

-17-

engineering meetings, to fellowships, to hospital administration
institutes, to the publication of the Bulletin, to the transla-
tion of the United States Pharmacopoeia, to the incidence of the
pestilential diseases, plague, smallpox and yellow fever, to
typhus, and to the financial position of Member States with relae
tion to payment of quotas to the Bureau. The Director regretted
that activities in nursing and nursing education had been prace
tically abandoned because of lack of funds.

The cash balance on November 30th, 19/6, was reported to be
$141,000, somewhat less than that of the previous year and con-
siderably less than the amount needed for a year's operation.

2. Pan American Sanitary Organization - 197

The XII Pan American Sanitary Conference, held six months
after the International Health Conference which had drafted the
Charter of the World Health Organization, authorized a complete
reorganization of the Pan American Sanitary Bureau, deliberately
planned to make it possible for the Bureau to function as the
Regional Office of the World Health Organization.#

The Conference determined the creation of the Pan American
Sanitary Organization with four component parts, namely:

(a) The Conference

(b) The Directing Council

(c) The Executive Committee

(d) The Pan American Sanitary Bureau

The Conference elected the Executive Committee and provided for
calling the First Meeting of the Directing Council to approve the
Constitution embodying the recommendations of the Conference.
This Constitution (Buenos Aires, October 19,7) provides that:

*¥The Constitution of the World Health Organization (Chapter XI
Regional Arrangements) provides for Regional Committees to fornu-
late regional policies, tc supervise the activities of the Regional
Office and to recommend additional regional appropriations to carry
out programs not provided for by the central budget cf the World
Health Organization. It provides that the Regional Director is

to be appointed by the Executive Board in agreement with the Regional
Committee. These functions of the Regional Committee are so

similar to those of the Directing Council of the Pan American
Sanitary Organization, that adaptation can be almost automatic.
-16.-

1. The Conference shall be the supreme governing body
‘of the Organization, shall normally meet at four-year
intervals and be comprised of the delegates of the
Member Governments of the Organization and of any
other territory or number of territories to which
the right of representation has been extended;

2. The Directing Council, with representatives of all
Member States, shall meet annually, carry out the
policy decisions of the Conference and approve the
program and budget;

3. The Executive Committee, composed of seven Member
States elected by the Council for overlapping terms
of three years, shall meet at least every 3ix months;

and

4. The Bureau shall be the administrative organ, with a
‘Director: chosen by a two-thirds vote of the Conference.

The purpose of this reorganization was to give the Member
States direct and active control of the policies and program of
the Bureau and to develop a type of organization conforming
very closely to that of the World Health Organization. This was
essential in planning for the later intimate association of the
two organizations.

A comparison of the World Health Organization and of the Pan
American Sanitary Organization shows that the functions of the
World health Assembly which meets annually are discharged in the
case of the Pan American Sanitary Organization by the Conference
and the Directing Council. The functions of the Executive Board
of the World Health Organization are essentially those of the
Executive Committee of the Pan American Sanitary Organization.

The World Health Organization has no name other than “Secretariat”
for its operating agency, corresponding to the Pan American Sani
tary Bureau.’

The Directing Council met in Buenos Aires in 197, in Mexico
City in 1948 and in Lima in 1949. The list of countries repre-
sented at meetings of the Directing Council will be found in the
Appendix (Table 1). |

The Sixth Pan American Conference of Directors of Health was
held in Mexico City October ])-7, 198, immediately preceding the
Second Meeting of the Directing Council. This Conference which
was largely devoted to the presentation of recent techniques and
developments in public health problems, has been reported in
special publication No. 2h3 of the Pan American Sanitary Bureau,
1950. The Conferences of Directors of Health were initiated in
1926 to give more frequent contact among health workers and had
-19-

been possible through the Pan American Sanitary Conferences. With
the regular annual meetings of the Directing Council under the
1947 Constitution, such meetings may not be as important as pre-
viously. The question of future Conferences of the National
Directors of Health will be up for discussion at the XIII Pan
American Sanitary Conference.

The Executive Committee held ten sessions between April
1947 and April 1950. Details of representation will be found
in the Appendix (Table 2).

Details of Special Committees appointed by the Directing
Council are also to be found in the Appendix (Table 2).

2. Agreement with the World Health Organization
Article 5, of the Charter of the World Health Organization
provides that

“the Pan American Sanitary Organization represented by
the Pan American Sanitary Conferences and the Pan
American Sanitary Bureau -.. shall in due course be
integrated with the Organization. This integration
shall be effected as soon as practicable through com-
mon action based on mutual consent of the competent
authorities expressed through the organizations con-
cerned.

The Directing Council of the Pan American Sanitary Organiza-
tion (October 19h6) considered the problem of relati onship
between the Bureau and the World Health Organization and went on
record as opposed to any modification of the political and organic
regimen of the Pan American Sanitary Bureau. The Governing Coun-
cil of the Pan American Union resolved (1946) that Pan American
specialized organizations, in undertaking to collaborate with
specialized organizaticns of the United Nations, should under all
circumstances maintain their own identity.

The XII Pan American Sanitary Conference (Caracas 197) ap-
proved the general terms of an agreement to be negotiated with
the World Health Organization which should be signed only after
two-thirds of the American Republics had ratified the Charter of
the World Health Organization. The Directing Council, at its
First Meeting (Buenos Aires, September 19l7) drafted such an
agreement to be submitted to the First World Health Assembly
(Geneva 19h8). The Assembly approved this agreement except for
one article which was referred to the Executive Board for re-
drafting. The agreement, as altered by the Executive Board of
the World Health Organization, was given final approval by the
Directing Council of the Pan American Sanitary Organization at
its Second Meeting (Mexico, 1948). The condition that two-thirds
of the American Republics should ratify the Charter of the World
-20-

Health Organization was satisfied in April 1949, when Uruguay
became the fourteenth American Republic to join the World Health
Organization; the Agreement between the World Health Organization
and the Pan American Sanitary Organization was signed by the
Director-General of the World Health Organization and the Director
ef the Pan American Sanitary Bureau on May 2), 1949. Final appro-
val of this Agreement was given by the Second World Health Assembly
at Rome in June 1919, and the Agreement became operative on July 1
of the same year.

In the meantime, a special working agreement signed earlier
in the year had become operative on May 1, at which time all
functions of the New York Office of the World Health Organiza-
tion, excepting liaison with the United Nations and its specialized
organizations, were transferred to the Washington headquarters of
the Pan American Sanitary Bureau.

The World Health Organization-Pan American Sanitary Organiza-
tion Agreement provides that the Pan American Sanitary Conference,
through the Directing Council, shall serve as the Regional Conmit-
tee of the World Health Organization, and that the Pan American
Sanitary Bureau shall serve as the Regional Office of the World
Health Organization.

The Director of the Pan American Sanitary Bureau assumed the
post of Regional Director of the World Health Organization, for
the remaining part of the period for which he had been elected.

Through the existing arrangement, there is in Washington, a
single operating agency handling the World Health Organization and
the Pan American Sanitary Organization operations in the Americas.
The World Health Organization pays salaries for some positions at
the Regional Office, assigns certain of its professional staff to
the Office as special advisers, allocates funds for a percentage
of space and equipment costs in addition to funds alloted for
fellowships and special demonstration programs. :

The Pan American Sanitary Bureau has adapted its financial
procedure to that of the World Health Organization and has adopted,
almost in their entirety, the Staff Rules and Regulations of the
World Health Organization.

An attempt has been made to develop a combined PASB-WHO program,
but this has not been possible because of the World Health Organiza-
tion's procedure of giving final approval to each of its projects,
and of allotting funds only to individual projects as requested by
governments.
wll] -

h. Need for both Pan American Sanitary Organization and
World Health Organization

The question has been frequently asked, since the two or-
ganizations have begun to work together, why there should be
two international health organizations, one regional and one
world-wide and why the American Nations should contribute
separate quotas to the Pan American Sanitary Organization and
to the World Health Organization.

The answer to this question rests with the American Nations
themselves, which have been cooperating harmoniously for many
years through the Pan American Sanitary Bureau under the Pan
American Sanitary Code (Havana 192), a treaty ratified by all
of them. Under this Code, the Constitution cof the Pan American
Sanitary Organization (Buenos Aires 197) and the Agreement with
the World Health Organization (Washington 199), it is possible
for the Pan American Sanitary Organization to execute regional
programs with funds which could not be made available to the
World Health Organization. The alternative would be the abroga-
tion of the Code by all 21 Member States, the approval of a new
mechanism for assessing these same Member States for regional
programs of the World Health Organization, and finally, the devel-
opment of a process for obtaining funds assigned by the World Health
Organization to the Regional Office for the Americas for such regio-
nal programs.

Since the Constitution of the World Health Organization pro-
vides for decentralization with Regional Conmittees authorized
to propose regional budgets for programs to be financed by Member
States, it would be necessary, were the American States to conti-
nue with the present program, which cannot be financed from World
Health Organization Headquarters funds, to make a Regional Assess-
ment in addition to tmt for Headquarters. The question is not;
then, one of paying one or two quotas, since two quotas would
have to be paid in any case to finance present operations, but
rather one of having partial or total control of the regional funds
and of regional programs. As the World Health Organization, after
additional experience, comes to be more and more decentralized,
this issue will become of less and less importance. As a matter |)
of practical immediate importance is the fact that there ts still |
a ceiling on the contribution to the World Health Organization
from the United States which would make the present scale of
operations in the Americas tmpossible if the Bureau were to disap- |
pear and the World Health Organization were to remain alone in the !

eld.

   

S. Participation of Canada

The XII Pan American Sanitary Conference (Caracas 19)7)
@22-

officially recognized Canada as a Member State of future Pan
American Sanitary Conferences.

"Membership: A» The Pan American Sariitary Organiza-
tion ts at present composed of the twenty-one
American Republics. All self-governing nations of
the Western Hemisphere are entitled to membership
in the Pan American Sanitary Organization."

The Director of the Bureau has maintained contact with the
Ministry of Health of Canada since 197, at which time a visit
was made to Ottawa for the purpose of discussing the relation-
ship between Canada and the Pan American Sanitary Organization.

At the Second World Health Assembly (Rome, 1919) during
the discussion of the Agreement between the World Health Organiza-
tion and the Pan American Sanitary Organization, the representa-
tive of Canada raised the question as to whether any diplomatic
action would be required for Canada to participate in activities
of the Pan American Sanitary Organization as the Regional Office
of the World Health Organization. The point was answered to
Canada's satisfaction by referring to the Final Act of the XII
Conference and to the above-cited provision of the Constitution.
At the same time, it was pointed out to the Canadian Delegate
that full participation in the activities of the Pan American
Sanitary Organization would entail a certain financial obligation
to the Bureau. During an interview with the Minister and the
Under-Secretary of Health of Canada, late in 1919, it was learned
that the Ministry of Foreign Affairs had under study the entire
question of Canada's relationship to Pan American and other
international organizations. It appeared that Canada was par-
ticularly interested in the wording of the agreement to be
written between the technical Pan American Sanitary Organization
and the political Organization of American States. The matter
was not further discussed during the period covered by this
Report.

6. Participation of Non-Self-Governing Territories

The Constitution of the Pan American Sanitary Organization,
1947, provides that territories or groups of territories within
the Western Hemisphere, which are not responsible for thé conduct
of their international relations, shall have the right to be
represented and to participate in the activities of the Organiza-
tion. The nature and extent of the rights and obligations of
these territories or groups of territories in the Organization
-23-

shall be determined in each case by the Directing Counctl after
consultation with the Government or other authorities having
responsibility for their international relations.

The Directing Council, at its Second Meeting in Mexico
City, 198, at which official representatives of the Netherlands,
Great Britain and France were present as observers, took action
granting the following rights and privileges to Non-Self-Govern-
ing Territories:

"S. To declare that the Non-Self-Governing countries of
the Western Hemisphere be offered the following rights
within the Pan American Sanitary Organization:

A. To participate with the right to vote in the
deliberations of the plenary sessions of the
Directing Council.

Be To participate with the right to vote in the
Committees of the Direting Council except
in those which deal with administration,
finances and the Constitution.

C. To participate on the same basis as the Mem-
bers subject only to the limitations mentioned
in sub-division (a) in matters relating to proce-
dure in the sessions of the Directing Council and
its committees such as presenting motions, amend-
ments and points of order, etc.

De. To propose subjects for inclusion in the provi-
sional agenda of the meetings of the Directing
Counetl.

E. To receive all the documents, reports and minutes
of the Directing Council.

F. To participate on the same basis as the Members
in all plans for the calling of special sessions.

Ge To appoint observers and to participate in dis-
cussions of the Executive Committee subject to
the same conditions which apply to the Members
of the Pan American Sanitary Organization who
are not members of the Committee although these
representatives are not eligible to membership
in the Committee."

At the Second World Health Assembly (Rome, 199) tt was proe
‘posed that countries responsible for the international relations
of territories or groups of territories lying within any region
-2h-

should be given the right to represent those territories in the
Regional Committee of the World Health Organization with vote on
all matters.

The Director of the Bureau held that the Assembly had no
power to legislate on this matter for the Americas, since ths
World Health Organization and the Pan American Sanitary Bureau
had agreed that the Directing Council of the Pan American Sanitary
Organization is to serve as the Regional Committee. This was
accepted by the Assembly, and the Western Hemisphere was excluded
from the action. The Directing Council, at its Third Meeting (Lima
1949) accepted the proposal made in Rome and resolved:

"To invite States Members of the World Health Organiza-
tion not having their seats of goverrment within the
Western Hemisphere which, '(a) either by reason of their
Constitution consider certain territories or groups of
territories in the Western Hemisphere, as part of their
natural territories or, (b) are responsible for the
conduct of the international relations of territories
or groups of territories within the Western Hemisphere, '
to participate on the same basis as the American Repu-
blics in meetings of the Directing Council as Regional
Committee of the World Health Organization."

At the same time, the Director was authorized to negotiate
with the appropriate administrative powers regarding the financial
contributions to be made to the budget of the Pan American Sani-
tary Organization in favor of territories in the Western Hemisphere.

In December 19k9, the Director discussed with representatives
of the Ministeries of Foreign Affairs of the United Kingdom, France
and the Netherlands, the question of contributions to the regional
budget. The question of such contributions was favorably received,
it being recognized, however, that there might be some delay due
to the necessity of establishing a formula and to determining how
the metropolitan powers would allocate such contribution to their
respective territories in question. France and the Netherlands
have both accepted quota assessments within the range proposed by
the Director of the Bureau. These quotas now await only the appro-
val of the Directing Council.

7+ Political Problems Related to Organizational Meetings.

As noted earlier, Dr. Cumming referred to political difficul-
ties which prevented full representation of the twanty-one American
nations at the XII Conference. He proposed at that time, that:

“every country which offers to serve as host
to a Pan American Sanitary Conference, must
likewise guarantee that it will welcome all
the countries which have a right to be repre-
sented."
=25-

A similar situation arose in connection with the Third
‘Meeting of the Directing Council of the Pan American Sanitary
Organization at Lima in 1949.

Previous to the holding of this meeting, the Government
of Peru gave official assurance of the friendly way in which
the technical representatives from all Member States would be
received. In spite of this assurance, some Member States were
not represented because of political differences.

In preparation for the XIII Pan American Sanitary Conference,
the host government has given official assurance of the friendly
reception which will be given to delegates from all Member States
and has officially declared that such delegates will be housed at
the expense of the Government during the meeting of the Conference.

The Council of the Organization of American States has recom-
mended to the Governments of the American States that representa-
tion at technical conferences should be independent of political
considerations and it is hoped that a tradition can be built in
the Americas that political considerations must not influence

‘attendance at technical meetings such as Sanitary Conferences and
meetings of the Directing Council.

Since it is impossible to foretell four years in advance the
political tensions which may prevail, it may be wise until such a
tradition does exist, to alter the Constitution go that the seat
of Sanitary Conferences will be set by the Directing Council two
years before the Conference, instead of by the preceding Conference.

III-e RELATIONS WITH OTHER ORGANIZATIONS
1. Inter-Governmental Organizations
A. Organization of American States

The First Pan American Sanitary Conference (1902), which
created the Sanitary Bureau, was called as a result of a Resolu-
tion of the Second Pan American Conference of American States
(1901-1902). Both the Conference and the Bureau were, from the
beginning, technical and not political in character.

The independence of the Bureau as a technical, non-political
organization was confirmed by the Pan American Sanitary Code
(Havana, 192) Chapter IX, Article 54, which reads as follows:-

"The organizations, functions and duties of the
Pan American Sanitary Bureau shall include
those heretofore determined for the Interna-
tional Sanitary Bureau by the various inter-
national sanitary and other conferences of
-26—

American Republics, and such additional administra-

tive functions and duties as may be hereafter de-

termined by fran American Sanitary Conf erences."

Among the documents circulated to the American Governnents

to be considered at the IX International Conference of American
States (Bogoté&, 198) was a draft charter of the Organization
of American States. A reading of this document suggested that,
were the charter to be approved as written, the Pan American
Sanitary Bureau would, as one of the specialized organizations
of the Pan American system, become a technical section of a
political organization as was previously the Health Section of
the League of Nations and, as is at present, the United Nations
Intérnational Children's Emergency Fund. The Director of the
Bureau protested to the Secretery General of the Organization of
American States and personally interviewed the Ministers of
Foreign Affairs of eight of the American Republics. On all sides,
the Director received assurances that it was not the purpose of
the authors of the charter to interfere in any way with the free
operation of the Bureau. The charter, as finally approved, bears
out this assurance. In reading that document, emphasis should be
placed on the recognition of the validity of pre-existing treaties
and upon the working of individual articles** in such a way as to
make the corresponding provisions facultative for each specialized
organization.

 

The Charter of the Organization of American States authorizes
the signing of formal agreements between the Council of the Or-
ganization and Specialized Organizations. Thorough discussion by
members of the Council and Executive Committee of the Pan American
Sanitary Organization resulted in an agreement between the two
organizations signed in May, 1950. This agreement fulfills the
requirements of the Pan American system while at the same time it
recognizes, but does not interfere with, the functions of the Bureau
as the Regional Office of the World Health Organization.

Legal opinion has been expressed that there is nothing incompat-
ible in the agreements now in existence between the Bureau and the
World Health Organization, and between the Bureau and the Organiza-
tion of American States. The Pan American Sanitary Bureau is the
first specialized organization of the Pan American system which
has completed agreements with the corresponding specialized organi-
zation of the United Nations and with the regional political
organization (Organization of American States). It is presumed
that this arrangement may form the pattern of collaboration between
megional organizations and those of the United Nations in other
fields.

¥ Charter of the Organization of American States, Arts. 14, 18 and 33.
we Charter of the Organization of American States, Arts. 53 and 99.
=27-

On the operating level the Bureau has encountered always
a most friendly and collaborative spirit among the officers and
staff of the Pan Americen Union. When, with the expansion of
the staff of the Bureau and the simultaneous expansion of the
staff and activities of the Union, it became necessary to seek
additional space, the Union collaborated wholeheartedly in
taking quarters with the Bureau, and, during the first year and
a@ quarter, paying the bulk of the rent.

The complete separation of the accounting and other servi-
ces of the Bureau from those of the Union has been forced by
the growth of the two instituticns and not by any lack of mutual
understanding.

Be American International Institute for the Protection of Childhood

Dr. John D. Long represented the Bureau at the meeting of
the Council of the American International Institute for the Protection
of Childhood in Montevideo in October-November 1947. At this
meeting, Dr. Long proposed the adoption of a Childrents Code.

The Director of the Pan American Sanitary Bureau attended the
Ninth Pan American Children's Congress at Caracas in January, 1948.
At this Congress, it was decided that the Children's Code should
be lkmown as the Declaration of Caracas and should be issued as a
joint declaration of the Institute and of the Pan American Sanitary
Organization, if and when approved by the Directing Council. The
Declaration of Caracas was considered by the Directing Council at
its Second Meeting in Mexice City in 191.8 and approved with the
pe cumendatson that the following declaration of principles should

e added:

"The Pan American Sanitary Organization believes
that all health activities, the objectives of which are
to guarantee to the child a harmonious physical and
mental development, must be based on the family unit,
of which the child is an integral part; the mternal
and child health services being entrusted to the Na-
tional Public Health Departments which wil] maintain
the closest possible contact and collaborate with the
agencies concerned with maternal and child welfare."

The Directing Council of the American International Institute for
the Protection of Childhood at its meeting in Montevideo on April 2,
1949, expressed general satisfaction with the fact that the Pan
American Sanitary Organization was interested in the family but

did not make the proposed addition to the Declaration of Caracas.
The Directing Council of the Institute at the same time reaffirmed
the fundamental principle that:
-28-

“the protection of the child and of the adoles-
cent must be constituted preferably on the basis of
a central organism which will unify all factors -
medical, jurisdictional, social, educational and
economical - which undividedly make up the child's
integral problem.”

The Regional Consultant on Maternal and Child Health atten-
ded the Meeting of the Council of the Institute in Montevideo
in May 1950 as observer of the Pan American Sanitary Bureau and of
the World Health Organization.

The Declaration of Caracas, as amended , is included as an
annex in this Report.

Ce. United Nations International Children's Emergency Fund

Karly in 199, the Director of the Pan American Sanitary Bu-
reau was requested to prepare proposed health programs for Latin
America to be financed in part from a sum of $2,000,000 which
UNICEF was preparing to allocate to Latin America. On February 22,
1949, the Director discussed, before the Program Committee of the
Executive Board of UNICEF, possible ways of spending emergency
funds rapidly in Latin America for maximum results with minimal
need of highly trained personnel. In “arch of the same year
definite proposals were presented, including yaws eradication
projects for Haiti and the Dominican Republic, insecticidal programs
for Central America, typhus control programs for Bolivia and Peru,
a diphtheria and pertussis immunization campaign for Chile,, a BCG
pro ject for Mexico and a BCG study for Brazile These projects
were approved with the exception of the BCG study for Brazil and
with the addition of a diphtheria immunization campaign for Colom-
bia, by the Executive Board of UNICEF and by the Joint Committee
of UNICEF and the World Health Organization. Later, the ‘orld
Health Organization and the Children's smergency Fund entered into
an agreement whereby the technical orientation for all UNICEF
medical and health supply projects was to be furnished by the World
Health Organization. In the meantime, the Pan Amrican Sanitary
Bureau and the World Health Organization had signed the agreement
whereby the Pan American Sanitary Bureau serves as the Regional
Office of the WHO in the Americas. Thus the responsibility for
handling the technical aspects of UNICEF programs in the Americas
still remains with the Bureau.

A considerable amount of time and energy of the small staff
of the Pan American Sanitary Bureau during the past tifteen months
has been devoted to UNICEF projects.
-29-

Toward the end of 1949, a project calling for the expenditure
of $500,000 in four states of Brazil was prepared and approved by

the Executive Board of UNICEF and funds allocated to Brazil.

Representatives of the Bureau have visited Haiti, the Domini-
can Republic, British Honduras, Honduras, Nicaragua, Guatemala,
El Salvador, Costa Rica, Colombia, Peru, Bolivia and Chile with
representatives of UNICEF in order to work out the details of pro-
posed projects with the national authorities of each country.

Representatives of the Regional Office of the World Health Organi-
zation are now on duty in Haiti, in Central America and in Colombia
in connection with UNICEF projects. Additional funds are to be
made available for Latin America, and additional programs are being
prepared for consideration in the near future.

2- National Agencies of Member States
Ae Institute of Inter-American Affairs

The program of the Institute of Inter-American Affairs has
been developed in 18 American Republicse In its early years, the
Thstitute of Inter-American Affairs financed a number of projects
which were carried out by the Pan American Sanitary Bureau.

The Institute and the Bureau have collaborated in the holding
of two Inter-American Regional Sanitary Engineering Conferences
hela in Rio de Janeiro and Caracas in 196 and two Inter-American
Congresses of Sanitary Engineering held in Santiago in 1948 and
Mexico City in 1950. They have also collaborated in activities
connected with the development of the Inter-American Association
of Sanitary Engineering and certain projects in the field of
nurses! training.

Within individual countries, the Bureau collaborates through
agreement with the national health authorities in the projects
supported by the Institute of Inter-American Affairs as it does
in regular national health projects. As the declared objectives
of the Bureau and of the Institute are identical, namely, the
strengthening of national health services, it is inevitable that
these two organizations will be drawn into more intimate collabora-
tion as the program of the Bureau develops.
Be United States Public Health Service

The long history of cooperation of the United States Public
Health Service with the Pan American Sanitary Bureau has continued
but with somewhat altered relations during the period 19\7-1950-
During the long period of the Bursauts existence when no funds
were available for professional personnel, doctors, nurses, sani-
tary engineers and scientists were assigned to the bureau by the
United States Public Health Service. In 196 practically all of
the professional personnel of the Bureau came from this source.

through 197 and 1948, the Publie Health Service paid the |
salaries of the Assistant Director, the Chiefs of the Lima and
Guatemala Zone Offices and for other officers and personnel of
the Service assigned to special projects. During 1949, officers
of the Public Health Service except those working on specific
programs, who continued to serve the Bureau, were placed on a
leave-without-pay status and their salaries were assumed by the
Bureau.

Grants-in-aid have been made to the Bureau by the Division
of Grants and 7ellowships of the National Institutes of Health
of the United States Public Health Service during 197 to 1950,
amounting to $29,165.50. These grants are for specific programs
in research in (1) malaria, (2) onchocerciasis and (3) venereal

isease.

The Bureau maintains close relationship with the Officer of
International Health Relations of the United States Public Health
Service. Frequently the Bureau calls upon other divisions of the
Public Health Service for advice and consultation and obtains
assistance in recruiting personnel for specific duties. The close
cooperation between the two organizations has been of mutual benefit.

Ce National Yellow Fever Service of Brazil and Oswaldo
Cruz Institute of Brazil

The resolution of the Directing Council (Suenos Aires 197)
making the dureau responsible for the coordination of programs
for the eradication of Aédes aegypti from the American Continent,
found the sSureau without properly trained staff and with only very
limited funds with which to operate. Under these conditions it
was possiols for the Bureau to take the initiative immediately in
the attack on Aédes acres only because of the full cooperation
of the National Yellow Fever Service of Brazil which has made
medical officera and inspectors and some very critical supplies
available to the Bureau from the berinning. It is no exaggeration
to say that the Sureau'ts program for the coordination of activi-
ties in many countries in the eradication of Aédes acayets is
based upon the use of personnel made available Sy the National
=31-

Yellow Fever Service of Brazil. The Brazilian staff made availa-
ble to the Bureau for this project has been kept on the Brazilian
payroll and has received travel and living expenses from the Bureau.

The collaboration with the National Yellow Fever Service of
Brazil was carried out on an informal basis until early in 1950
when an agreement was made with the Brazilian Government covering
this collaboration with the National Yellow Fever Service and also
with the Oswaldo Cruz Institute which, on January 1, 1950, became
responsible for the production of yellow fever vaccine and for
the serological and pathological studies of yellow fever. (See
Yellow Fever in Part II).

Ce. Carlos Finlay Institute - Bogota

The Pan American Sanitary Bureau has made wide and free use
of the services of the Carlos Finlay Institute in BocotAé in
supplying pathological and serological services to neighboring
countries and in furnishing yellow fever vaccine. The Carlos
Finlay Institute has been responsible for the serological testine
of human and monkey sera from Panama where the discovery of yellow
fever in 1948, 19h9 and 1950 called attention to the importance
of this problem. The studies in Panama carried out by the joint
Yellow Fever Service of the Republic of Panama and the Canal Zone
have been most important additions to the existing knowledge of
jungle yellow fever in that part of the world. ;

The collaboration of the Carlos Finlay Institute was on an
informal basis until 1950 when an agreement was made with the
Ministry of Health providing for Bureau collaboration in the
activities of the Institute on such a basis as to justify the
continued examination of sera and of pathological material and

the supplying of yellow fever vaccine to neighboring countries as
needed. :

3- Non-Governmental Organizations
Ae The Rockefeller toundation

The Rockefeller Foundation in February 19l7 granted a leave
of absence from the staff of the International Health Division to
the Director of the Pan American Sanitary Bureau and, moreover,
paid his salary for the year 1917. In 197, the Rockefeller
Foundation made a grant of funds to the Bureau to cover the sala-
ry and traveling expenses of a nursing consultant for a period of
16 months. This contribution made it possible to begin activities
in this field a full year earlier than would have otherwise been
possible. A close spirit of collaboration has existed between
the representatives of the Bureau and of the Foundation, especially
in the field of nursing.
-32=

Be The Kellogg Foundation

Initial plans had been made in 1946 for the collaboration
with the Kellogg Foundation in the development. of an Institute of
Nutrition for Central America and Panama. This cooperative pro-
ject is an attempt to solve the local nutritional problems of
the area itself since it is known that the nutritive value of a
food produced in one area may vary widely from that of the same
food produced elsewhere. In the Institute of Nutrition of Cen-
tral America and Panama, several countries cooperate in supporting
a single institute rather than attempt individual national pro-
jects e

The Kellogg Foundation has taken great interest in this pro-
ject and has financed to a large extent the equipment of the
laboratory in Guatemala City, the training of physicians, agrono-
‘mists, nur3ges and bio-chemists from the participating countries
and has made funds available to the Pan American Sanitary Bureau
for the organization of its Section of Nutrition.

The work of the Institute will be reported on elsewhere in
this Report.

In 1950 the Kellogg Foundation agreed to collaborate in the
installation of the Institute of Nutrition in Quito, Ecuador, to
which the Bureau will give technical assistance.

IVe ORGANIZATIONAL PROBLEMS FACING THE PAN AMERICAN SANITARY
, BUREAU

The creation of the Pan American Sanitary Organization to
parallel the structure of the World Health Organization, and the
expansion of the scope of international health work in the Americas,
forced a complete internal administrative reorganization of the
Pan American Sanitary Bureau.

The organizational problems which the sureau faced as a re-
sult of the increased program ana of the constitutional changes
approved by the Caracas Conference, can be conveniently discussed
under four headings:

le Permanent Professional Staff
2.e Finances
2. Adequate Headquarters Space, and
« Decentralization of Administration.

1. Pormanent brofessional Staff

The resolution which created the International Sanitary Bureau
in 1902 provided that each country should be responsible for paying
(333+

the salary and travel expenses of its nationals serving with the
Bureaue Even after the reorganization of the Bureau in 192k,
under the Pan American Sanitary Code, no provision was made for
paying the salaries of the Director and of a permanent profes-~-
sional staff. Throughout the period from 1902 to 19.7, the
professional staff of the Bureau consisted almost entirely of
United States Pyblic Health Service officers on loan to the Bu-
reau.e. It is no exaggeration to say that at the time of the XII
Pan American Sanitary Conference in Caracas, the Bureau had no
professional public health staff whose entire salury was paid by
the Bureaue This situation has been changed and provision has
been made for the development of a truly international professional
staff.

At the present time, all staff members are on the payroll of
the Pan American Sanitary Bureau or of the World Health Organiza-
tion with the exception of staff on loan from the National Yellow
Fever Service of Brazil in connection with measures for the
eradication of the Aédes ae ti mosquito, and personnel assigned
from the National Institutes of Health of the United States Public
Health Service in connection with special studies in Guatemala.

The reorganization of the Bureau and the expansion of its
operations has required not only the development of the sureau's
own medical, technical and scientific staff but also an expansion
of the administrative and clerical force.

From 32 employees on the general sureau payroll in December
1946, the staff expanded to 171 in “pril 1950. (Table  - Appen-
dix).

fhe increase in professional staff was practically from zero
since the United States Public Health Service which had previous-
ly generously assigned professional officers to the staff of the
Bureau ceased to loan officers to the Bureau in 1948. (Table 5 -
Appendix). .

In December 19.6, the Bureau's staff of 32 persons represented
eight American Republics; an additional 56 employees were working
under the supervision of the Bureau but were paid from other sour-
cese In April 1950, the Bureau had 171 employees, &7 others paid
from funds administered by the Bureau, and 28 from world Health
Organization funds. These 266 employees represented 16 American
Republics, Great Britain, Canada, Australia, New Zealend, British
Guiana and Spain. (Tabies 6, 7 and 8 in Appendix).

2e Finances

At the First Fan Americen Sanitary Conference in 1902, the
annual appropriations for the sureau were fixed at 45,000. This
was increased tc $20,C00 in 1920 and to not less than #50,000 in

We
~ the

192). In 1938, the assessment on Member States was set at
us.$.40 per thousand population which was calculated to give
not less than US.#100,000 annually. With the gradual increase
in population of Member States, the income of the Bureau had _
risen to $115,000 at the time of the XII Pan American Sanitary
Conference in 1947.

During World War II, the activities of the Bureau were
greatly expanded with funds contributed for specific projects
by certain philanthropic foundations and particularly by agen-
cies of the United States Government. During the four years
16h3-19)7, $1,945,800 outside contributions were spent on such
specific projects. Of this amount, $145,200 came from private
foundations; $65,100 from the Mexican Government am $1,735,500
from agencies of the United States Government.

After World War II, several United States agencies withdrew
support cf special projects, with an inevitable decline in the
Bureau's activities. Funds withdrawn by the United States Govern- .
ment included a considerable amount for fellowships and for field
projects.

During 1915-196, the last year before post war reductions
in the United States contributions became effective, the Fan
American Sanitary dureau program cost over $600,000, while in-
come from assessments against the twenty-one Member States amounted
to only $115,000. But the contribution from other agencies did
not entirely cover the increased activities of the Bureau, and rou-

tine pependitures rose from $87,000 in 192, to almost $160,000
in 196.

The XII Pan American Sanitary Conference voted to expand the
program of the bureau and gave a mardate to the Directing Council
te:

“prepare an adequate budget for the work of the
Bureau which, in accordance with Article LX of
the Pan 4merican Sanitary Code, shal] be alloca-
ted among the signatory Governments in accordance
with the system under which the expenses of the
Pan American Union are allocated."*

The Conference did not act to improve the finances of the
Bureau immediately through a failure to realize that the Bureau's

cash on hand was not really a reserve but essentially a working
eapital fund required to finance activities while awaiting pay-

#Final Act: XII Pan American Sanitary Conference
-35-

ments from Member States. At the time of the XII Conference,
the Bureau was overspending its income by 50%, despite the fact
that it was paying neither rent nor salaries of its professional
staff. In 197, the working capital funds were rapidly depleted
and completely exhausted early in 198.

The problem of properly financing the work of the Bureau
has taken a disproportionate amount of time and energy of the
Director during the period 1947-1950, and has not yet been settled
satisfactorily.

At its First Meeting (April 1947), the Executive Committee,
after receiving the Report of the Director on the precarious
financial situation of the Bureau together with a budget propo-
sal of $1,285,000 for 1948, agreed to recommend to the Directing
Council an increase of the quota of Member States from $.l.0 to
$1.00 per thousand population. Since this increase would produce
only some $285,000, a sum entirely inadequate for the needs of the
Bureau, the Director requested and received authorization of the
Committee to approach individual governments for voluntary supple-
mentary contributions.

During 1947, before any response had been received to the
request for supplementary contributions, there came the sugges-
tion that special funds might be made available to the Bureau for
projects requested by interested countries through diplomatic
channels. ‘this suggestion was not accepted because it is felt
there should be free collaboration of the American Republics in
health programs through the Bureau at the technical level, without
resort to diplomatic negotiations.

The response of certain Member Governments to the appeal of
the Director for voluntary supplementary contributions was grati-
fying and led to considerable optimism at the First Meeting of
the Directing Council (September 197). The Directing Council
approved a budget for the calendar year 1948 of $1,300,000 based
on:

(a) A quota of $1.00 per thousand population for all
Member Governments. ($285,000).

(ob) A voluntary supplementary quota to be in accord
with the economic capacity of each Member, to be
negotiated by the Director of the Bureau with
individual governments. Supplementary contribu-
tions were estimated at $1,000,000.

The change of the Fiscal Year to agree with the calendar year
in 1948 made the increased assessment applicable six months earlier
-36-

than would otherwise have been the case, but the corresponding
increase in receipts was not available during the first six
months of the year, so that funds were completely exhausted about
March of 1948. The 198 experience emphasized the inevitable
delay which must occur between the voting of an increased budget
by an international organization and the receipt of the corres-
ponding quota contributions. The approval of the budget of an
international organization by its council or assembly is not

an act of appropriation but only the first step leading, even-
tually, to appropriation by menber governments. the resultant
delay in appropriation and payment makes it necessary to consider
the financing of international organizations with more anticipation
than is necessary for national services.

+

After its working capital fund was exhausted , the Bureau had
to depend on borrowed funds for some months. the situation was
relieved in June 19/8, by the simultaneous receipt of Mexico's
quota for the last half of 197 end for 19/8 plus a voluntary
‘supplementary contribution of almost $200,000. This was the first
of the voluntary supplementary contributions to be received and ,
came at a most opportune moment.

Notwithstanding the approval of a budget of $1,300,000 for
1948 and the generosity of Member States shown by their supplemen-
tary contributions, actual expenditures from quota funds during
the year 1918 amounted to only E310,660% The expenditure of an
appreciably larger amount would have left the Bureau without
operating funds for the first half of 199.

 

At the Fourth Meeting of the Executive Committee (May 1948),
opposition developed to the financing of the Bureau through the
relatively small quota of $1.00 per thousand population plus
annual voluntary contributions from Member States, as approved
by the Directing Council in 19}?, and it was recommended that the
entire amount needed for the Bureau should be on a regular quota
basis.

¥ Expenditures in 1947, unbudgeted, amounted to $176,000 against.
assessed income of $115,000.

**Voluntary supplementary contributions have been received as

follows: A
Mexico 19L,8 19),,689.6 “
Venezuela 4 . ater a
El Salvadcr " 2,538.79: _?
Chile " 1,859.46".
Brazil 19h9 Cr 5,000,000 .00:-

Dominican Republic 1950 $5 ,000.004,
-37=

Previous to 1918, the quota assessments of Member States
for the support of the Pan American Union and of the Pan Ameri-
can Sanitary Bureau were ona per capita basis. However, in
the financing of the United Nations, a formula based on the
estimated ability to pay of the Member States was used. The
United States Government contributed just over 85% of the |
quotas payable to the United Nations by the American Republics
in 197 whereas, on the per capita basis, the United States
contributed only 52% to the support of the Pan American Organi-
zations. This disparity led to a reconsideration of the formula
for allocation of quotas paid to the Pan American Union. The
result was a decision, taken early in 1948 , that contributions to
the Pan American Union (and to the Bureau) shovld be based oe
on population and 60% on ability to pay, as estimated by the
United Nations. This formula resulted in increasing the assess-
ment of the United States to 72.13%.

Some opposition was voiced in the Executive Committee to
the new scale and, at the same time, it was claimed that the
disparity in econaaic conditions among the American Nations would
make it difficult to provide an adequate budget for the work of
the Bureau through assessments based on any existing formula.
The Executive Committee instructed the Director to prepare a new
scale of contributions which would reflect not only population
and ability to pay, but also the declared interest of countries
in international health as indicated by their voluntary supple-
mentary contributions to the Bureau.

It was proposed that the new scale should be based on two
formulae, first that established by the Pan American Union, to
be applied to the administrative section of the Bureau budget and
second, a new formula to be applied to the field operations section.

The Executive Committee instructed the Director to request
Member Governments, in the name of the Committee, to authorize
their representatives at the Second Meeting of the Yirecting
Council to approve a program and budget for the first half of
1949 of $700,000 and for the Fiscal tear’19\9-1950 of $2,000,000.

The Directing Council at its Second Meeting (Mexico, Sep-
tember 1948) maintained the calendar year as the Fiscal Year
and approved a buaget of $1,700,000 for 1949 to be assessed to the
Member States according tc the formula adopted by the Pan American
Union.

fhe change in financial procedure, at this time, consisted
not only of altering the percentages of payment by individual
countries, but also of establishing a variable contribution from
year to year based on an approved annual budget.
=38—

Experience was toshow how unrealistic this procedure can be,
for an international organization, for budgets approved late in
the preceding fiscal year to be financed from funds assessed at
the same time against a number of countries.

There is little relation between an increased budget voted
in September of one year for the immediately following calendar
year and the availability of funds duri the two-thirds of that
year. In 1949, for example, less than 2% of the quotas due had
been received by June l,and the payment of the United States,
which accounted for 72% of the funds, was available only in August.

only $786,423.95 was spent during 1949 of the budget of

$1,700,000%

At the Third Meeting of the Directing Council (Lima, October
1949) a budget of $1,742,000 was approved after making certain
allowances for the assumption of administrative expenditures by
the World Health Organization.

In 1950, as in 19,9, less than 2% of the assessments had
been received by June 1 and it is apparent that, in this second
year of an approved budget of about $1,700,000, the expenditures
of the Bureau must not exceed $1,400,000 if adequate funds are
tost, available for operating expenses during the first half of
1951.

There has always been a great discrepancy between the budgets
approved for the period 19l,8-1950 and the amounts spent by the
Bureau from funds actually available.*

 

Year Approved Budget Spent

 

1948 $2» 300,000.00 #319027 e2l

1949 1,700 ,000.00 786,23 .95

1383 1,742,500 +00 560,087.25 ( Jan-June)
1948 - 1950 $1,742,500 -00 $1 ,666, 138.41

 

It is clear from these figures that obvious results from in-
creased budgets can become apparent only during the second year
{Pull results can come only some four to five years later).

#Detalled statements of income and expenditure will be found
in the Appendix.
-39-

At the Third Meeting of the Directing Council it became
evident that there exists a dangerous failure to realize the
importance of delays which occur between action taken by an
international organization and the receipt of funds assessed
against Member States by such action.

The Director's Report to the Third Meeting of the Directing
Council (Lima 1949) indicated that there might be some $900,000
on hand at the beginning of 1950." The Report also showed that
unpaid balances of Member States would be some $250,000.

A proposal was made that the sum of these two items, $1,250,000,
should be credited to the Member States in the proportion of their
contributions to the 1919 budget and that an assessment be made for
1950 against Member States only in the amount of $492,500 to com-
plete the total of $1,712,500.

At the same time it was proposed that provision should be
made for a working capital fund of $1,000,000 to be raised by
contributions from the Member States in the same proportion as
regular contributions, but with the proviso that Member States
would maintain ownership in that part of the working capital
fund contributed by them.

‘ When it was pointed out to the Directing Council that the
working capital fund existed in part because of the supplementary
contributions of Mexico, Chile, El Salvador, Venezuela and Brazil,
the proposal was not approved.

In spite of the rejection of this proposal, it is important
to point out that arguments in its favor were erroneous. These
arguments were:

(a) that it would cause the Bureau to receive more
promptly the quotas from Member Governments, and

(b) that the Bureau would have as much cash with which
to operate in 1950-51 as with the continuation of
the established procedure.

While it is true that there are some unreasonable delays in
payments by Member Governments of Bureau quotas, the most im-
portant delays are inherent in the mechanism whereby funds are
appropriated. In many countries there is no means of speeding
payment to the Bureau. This statement applies to those countries
which cannot make payments at the beginning of the calendar year
but must await legislative action, which may be delayed.

#This amount included something over $200,000 calculated at the
official rate of exchange on deposit in Cruzeiros in Brazil,
but not readily convertible to dollars at that rate.
-lLo-

The failure to receive the difference of almost $200,000
from the most important contributor, the United States, and the
extra delay in receiving quotas from other countries due to
necessity of altering the procedure of payment, would have left
the Bureau without funds with which to operate during the first
half of 1951.

The attempt to put international health organizations on
an annual budget basis with assessments to be paid by govern-
ments during the current budgetary year is highly impractica-
ble as has been shown during the past four years, by the ex~-
periences of the Pan American Sanitary Bureau. The World Health
Organization has had a similar experience and has been forced to
cut 1950 expenditures well below the budgeted amount. Even those
countries whose payments are made promptly following legislative
approval are generally at least six months late in payment, and the
full effect of increased quotas cannot be obtained in less than
two to five years following approval.

Some method must be devised for taking care of the lag between
approval of Bureau budgets by the Council and appropriation and
payment. One solution would be the creation of a sufficiently
large working capital fund to cover all possible delays in payment.
Another would be to look further into the future and get approval
of how much should be available for operations of the Bureau two
years later and make the next year's assessment correspond to the
needs of the following year rather than to current expenditures.
Another suggested solution is to get the International Bank to
advance funds to the amount of assessments voted against individual
Member States to take care of current needs. Once a satisfactory
method has been developed, it should permit realistic budgets to
be worked out with full knowledge of the availability of funds.

Experience has shown that international health activities can-
not be developed well by short-term planning. Personnel cannot
be improvised and time is required to develop cooperative programs
with individual governments. Much sounder wark could be done in
this field were it possible to get an agreement on a fixed amount
per year for several years or gradually increasing amounts during
a period of years.

3. Adequate Headquarters Space

As early as 1939-ho*, the Annual Report of the Director of the
Pan American Sanitary Hureau emphasized the pressing need of the
Bureau for adequate space for its growing activities. It was
assumed that the new building of the Pan American Union, when
built, would solve this problem. Three years later, in his re-
port for 1942-1943, the Director stated that the space problem

 

*Publication 153, September 190.
“hi.

of the Bureau had become acute and that it was becoming more and
more apparent that, with the growth of the Bureau, a separate
building would eventually be necessary.

After another four years, at the time of the XII Pan Ameri-
can Sanitary Conference in 19L,7, the headquarters of the Pan
American Sanitary bureau were located in three small rooms and

a corridor in the Pan American Union Suilding, with the Library
stored in an underground tunnel.

In September 197, a move was made to the present headquar-
ters at 2001 Connecticut Avenue. This move was possible because
of joint occupancy with certain sections of the Pan American Union
which paid most of the rent until January 1949. With the expan-
Sion of activities, it was necessary to use, during 19h9 for the
combined Bureau and World Health Organization staff, the entire
building at 2001. In addition two small buildings on Connecti-
out Avenue are being used in 1950.

The present headquarters are inadequate and the division of
the staff in three buildings, none of which were constructed for
office use, makes efficient administration difficlt. The housing
problem is still acute and an early solution is necessary.

The request of the Director in 199 to the Third Meeting of
the Directing Council for authorization to make provision for
permanent headquarters led to a discussion as to the permanent
site of the Bureau, with the representative of Mexico proposing
removal of the Bureau's headquarters to Mexico City. The Directing
Council failed to make a decision and referred the question to the
XIII Pan American Sanitary Conference. The delay entailed by this
action has been unfortunate since present quarters are badly crowded
and any further extensions of operations to other buildings would
further complicate present administrative difficulties.

A Committee with representatives fram the United States, Mexico
and Peru to study the question thoroughly and to report thereon to
the Conference was appointed by the Directing Council in Lima,
October 1949. The Committee met in Washington in April 1950 and
will present its report to the XIII Pan American Sanitary Conference.

4e Decentralization of Administration

The health problems of the Americas are too complex, the
program of the bureau is too varied and the distances are too
great to permit centralized administration. Only through zone
and sector offices is it possible to maintain contact with the
health authorities of the interested nations and supervise field
activities.
-l2-

The Bureau's budgets have, in 199 and 1950, provided for
well-staffed sone offices. These have not been fully activated
because satisfactory decentralization has had to await the
development of the central organization at Headquarters, the
selection and training of professional staff and the actual
collection of sufficient funds to guarantee adequate financing.

Bureau offices have been maintained in El Paso, Guatemala,
Lima and Brazil (first at Sao Paulo, now in Rio de Janeiro).

Plans have been made for additional offices during 1950.

Ve PRINCIPLES AND POLICIES AFFECTING PROGRAMS OF THE BUREAU

Before presenting, in Part II, details of the activities of
the Bureau since the XII Pan American Sanitary Conference, it is
appropriate to consider briefly the principles and policies on
the basis of which the programs of the Bureau have been developed.

1. Inequality of Health Conditions in the Americas

As international health enters upon its second half centiry,
almost incredible differences exist in the health of different
peoples of the Americas, despite the efforts of the health autho-
rities of each nation and the collaboration of various organiza-
tions in the international health field. At one extreme, in the
United States, most epidemic ani environmental diseases are under
good control, and infant mortality 1s very low; increasing atten-
tion is given to the need for health centers and adequate hospital
facilities for the entire population with due consideration for
the degenerative diseases of old age. On the other hand, the
populations of some countries still suffer from such epidemic
diseases as typhoid, smallpox, plague, typhus, malaria and dysen~
tery; infant mortality is excessive, nutrition is inadequate, mo-
dern hospitals almost non-existant and the average age at death
is low. This discrepancy in conditions is reflected in the emphasis
placed on different phases of health work in different areas, and
it must be taken into consideration in establishing priorities for
the activities of the Bureau. Naturally, the Bureau will concen-
trate its work where the need is greatest and in fields where
essential knowledge is already available.

2e Epidemic Disease

The control of epidemic disease is a primary obligation which
was placed upon the Bureau when it was first organized in 1902 and
again emphasized in the Pan American Senitary Code of 192). It
is clear, then, that the collection and dissemination of information
-h2-

on disease-incidence, epidemiological studies, the development of
control methods and, upon reqest, the application of control
methods must be among the fundamental activities of the bureau.

Today it is difficult for public health workers in the United
States to realize that epidemic disease was serious in that coun-
try and constituted an effective deterrent to international travel
and trade only a half-century ago. In the century preceding the
organization of the Bureau, yellow fever ravaged the Americas from
Boston to Buenos Aires, cholera outbreaks were frequent and small-
pox was taken for granted. Just a few years prior to the birth of
the Bureau, bubonie plague had for the first time invaded the Ameri
cag and was still gradually spreading from country to country.

3- New or Limited Diseases or Disease Vectors

Among the most important functions of the Pan American Sani-
tary Bureau,as an international health agencysig to ald Member
States in the control of new or limited invasions by diseases or
disease vectors.

No adequate history of the migration of diseases, of inter-
mediate hosts, and of disease vectors has ever been written, but
it is known that such migrations have played, and continue to
play, an important part in the health and economic life of coun-
tries all over the world. The history of the discovery and
colonization of America is replete with references to epidemic
outbreaks of great severity. The ocean was a two-way highway,
and it is often difficult to differentiate between epidemics
caused by agents imported from Europe and Africa and those pro-
duced by American viruses among non-immune #uropean and African
immigrants. Among the important invaders at this time were un-~
doubtedly measles, smallpox, hookworm disease, yellow fever,
malaria and the Aédes ae ti mosquito, the urban vector of yellow
‘fever. It is interesting to note in this connection that after
four hundred years on the American continent, as late as thirty or
forty years ago, the ae ti mosquito was still advancing to new
outposts in the interlor of South America. The finding in 191
of the tse-tse fly, the vector of sleeping sickness, in Brazil
on planes from Africa, dramatically emphasizes the fact that

the history of transatlantic invasion by disease vectors is not
yet necessarily complete. i

The isolation of almost a score of viruses of unknown diseases
in Africa and the Americas during the studies on jungle yellow
fever in the past fifteen years indicates that unrecognizable
diseases may be lurking in the forests of one or another conti-
nent waiting for a favorable opportunity to spread to other regions.
alhe

The recent discovery in Venezuela of onchocerciasis, an
African filarial disease, previously known in the Americas only
in contiguous regions of Mexico and Guatemala, indicates that
the extent to which inter-regional migration of disease has ale
ready occurred may be much greater than is known.

In a similar way, the discovery of Bartonellosis (Verruga
Peruana) in severe epidemic form in southern Colombia some years
ago indicates that this disease, long thought to be limited to
Peru, may be able to spread far beyond its recognized boundaries.

The Bureau is the agency through which the continuing expan-
sion essential to the final success of eradication programs can
be obtained by the coordination of activities in all countries
interested in a given problem. An important example of this function
of the Bureau is to be found in the case of the program for the
eradication of the Aédes aegypti mosquito.

Both Bolivia and Brazil have eradicated Aédes aegypti within
their borders, but since the health services of these countries
cannot operate on the soil of their neighbors, it has fallen to
the Pan American Sanitary Bureau to coordinate simultaneous cam-
paigns in other countries in an attempt to eradicate ASdes aegypti
from the continent.

Similarly, for example, the campaign for the eradication
of yaws from Haiti, financed by the United Nations International
Children's Emergency Fund and the Ministry of Health of Haiti and
carried out under World Health Organization-Pan American Sanitary
Bureau technical orientation, depends for its final success on a
similar eradication campaign being carried out in the Dominican
Republic. Coordination here is a vital function of the interna-
tional health agency. Other examples of the Bureau's role in
overcoming the limitations imposed upon effective public health
work by political barriers, are the venereal disease and rabies
activities along the Mexico-United States border. Disease must
be pursued beyond political boundaries, and many projects must have
complete regional coverage.

4. Regional and Area Projects

The Bureau gives priority to projects of a regional character
Which strengthen the health resources of the entire region or of
a particular area and which may be, at the same time, of general
value to all countries of the Americas.

Support given by the Bureau to yellow fever laboratories in
Brazil and Colombia, replacing the traditional collaboration of
the Rockefeller Foundation, falls into this category of regional
projects. It is most important for the welfare of all that
studies be continued on the epidemiology of jungle yellow fever
-5-

and on improved methods of producing ami applying yellow fever
vaccine, and that the yellow fever laboratories in Rio de Janeiro
and Bozota should continue to serve as regional centers for |
pathological examinations, for immunity tests on human and mi-
mal sera and for the preparation and distribution of yellow fever
vaccine free of charge to governments in the Region.

During recent years, smallpox in the Americas has become
more seriouge In order to protect the entire population of the
Americes, there should be an intensive and continuous program of
vaccination and revaccination against the disease in all coun-
tries. The Bureau has encouraged the development of a dry vaccine
resistant to normal temperatures and is preparing to carry out
large-scale field demonstrations after which an attempt will be
made to coordinate national vaccination campaigns. Preliminary
discussions have already been carried out in Mexico, Peru, Boli-
via, meuador and volompla.

In the field of nutrition, under Bureau initiative and aus-
pices, the Institute of Nutrition of Central America and Panama
was created in order to benefit the countries of that sector.
The results of its work will be at the disposal of the Member
Governuents of the Institute and,through the Pan American Sani-
tary Bureau,are also available to other countries in the Hemisphere.

S- Standardization of Laboratory Procedures

An important phase of Bureau activities is related to the
standardization of laboratory methods and materials. In Guatemala,
Panama, vVosta HKica, Nicaragua, Honduras and El Salvador, and more
recently in Venezuela, Bureau consultants in serology have trained
local technical personnel in standard laboratory methods and proce-
cures and have coordinated the venereal disease laboratory programs
in those countries on a standard basis. The facilities and ex-
perience in these countries are available to other countries for
demonstration and training purposes. The Bureau has undertaken
a comparative study of antigens used in the Americas for the diag-
nosis of brucellosis as a preliminary move toward standardization
of diagnostic techniqes.

6. Debilitating and Crippling Diseases

The Bureau has taken as a basic principle, in establishing
priorities, the giving of assistance in raising the general health
level in regions affected by debilitating and crippling diseases.
In raising the general health level, the productivity of the area
is increased with a general economic gain. Major diseases which
fall within this class are malaria, yaws and hookworm disease.
- 6+

7- Improvement of National Health Services

The ultimate objective in international health must be to
build up the health departments of Member States until the entire
population is cared for by health centers, emphasizing maternal
and child health programs and, along with the long-term project,
it is reco:nized that such a program entails careful training
of public health workers of all categories out especially of pu-
blic health nurses. In the meantime, there are urgent health
problems for which relatively easy solutions not requiring highly
trained personnel are available. The Bureau works for the
development of health centers and for the training of public
heaith nurses and also stimulates the organization of special
services with relatively untrained personnel for handling certain
prosrans which can be made routine. Such special services do not
include maternal and child health programs which require well
trained personnel and cannot be separated from the health center
program without duplication cf effort and increased expense. The
protection of the child, in the final analysis, depends upon the
protection of the family.

8. Grouping of Special Services

AS an intermediate step in the development of national health
programs where coverage by health centers is impractical, the Bu-
reau advocates, wherever possible, grouping special serviceg under
a single administration. Thus it is advantageous today to handle
together all those diseases which depend on insect transmission
within the domicile in a single division responsible for main-
taining human dwellings free of insects rather than continue with
special services for malaria, yellow fever, plague, Chagas Disease,
fly-borne dysentery, etc. The insect-free dwelling becomes the
objective rather than the control of any individual disease.

Likewise, those diseases which are best controlled by routine
vaccination may well be grouped on a routine basis rather than
organized as special campaiens for individual diseases at times of
epidemic threat. For example, smallpox, yellow fever and typhoid
vaccine can well be given by the same team working in many regions
of South America.

9- Dissemination of Knowledge

Fortunately the effects of wide dissemination of disease and
disease vectors can be mitigated through an equally wide dissemina-
tion of knowledge of the means and methods of control and eradica-
tion. An interesting early example of the long-distance transfer
of a technique and of the necessary accompanying material was that
of smallpox vaccination not many years after the work of Jenner.
-\?-

Betweén 1803 and 1806, the Spanish carefully brought the cowpox
vaccine virus to the Americas and thence to the Philippines
through a series of transfers from one immigrant’orphan to ano-
ther, on the high seas. A more recent example of such a long
distance transfer was the application in 19-1945 in Egypt of
methods developed in Brazil in 1939-1940 for the eradication of
Anopheles gambiae. These are but two examples, separated in

6 by @ century and a half, of the type of interchange of tech-
niques which represents an important phase of international
health work.

The Bureau promotes improved health methods by the publica-
tion of technical reports, by carrying out demonstrations, by
institutes, by special training projects and through personal
contact with health officials. /

10. Bridging the Gap between Scientific Knowledge and Application
for the Benefit of Mankind

The bridging of the gap which exists at any given time between
the best available methods of combating disease in one place and
the application of that knowledge for the benefit of mankind else-
where, must ever be the responsibility of the international health
agency. Such an agency must be sensitive to the discovery of new
methods and techniques in any part of the world and be ready to
facilitate their early application elsewhere. The Bureau, through
coordinating medical and health studies, is instrumental in apply-
ing the research and scientific findings of one country to problems
existing in other districts or regions of the Americas.

ll. Consultant Services

In general, experience has shown that long term consultant
service by a staff member of the Bureau, repeatedly visiting all
countries in the region, bringing new ideas and new developments
observed in other countries, is one of the most effective mathods
of bridging the gap.

fhe Bureau cannot maintain however, a full staff of experts in
all fields and must be free to call upon national health services
for the loan of qualified leadera for consultant short-time con-
sultant services to meet special needs of Member States.

One of the most important functions of the Bureau is to fur-
nish consultant services on request to Member States.

12. Personnel Training
In the course of the last four years, it has become increasing-

ly clear that the coordination of education and training in the
broadest sense is one of the most important functions of the Bureau.
-h8-

No greater contribution can be made in the field of international
public health than making available to local personnel the informa-
tion and training required for a career in public health. In ad-
dition to graduate training at academic institutions, the Bureau
conducts numerous service training programs. ‘The Bureau has adopted
the practice that wherever it collaborates in a project, it is, if
possible, to be used for training purposes. In this manner health
work in one country serves as a training opportunity for the person-

nel of other countries.

While applications for fellowships may be initiated by in-
terested individual candidates, such applications must come to
the Sureau from the interested government service. The Bureau
does not entertain applications made to it directly by individuals.

In its own staffing practice, the Bureau places strong em-
phasis on public health training for its own professional personnel.
In the development of the teamwork so essential to successful well-
rounded health programs a common background of public health train- .
ing of all members of the team, doctors, engineers, veterinarians,
dentists and nurses, is extremely valuable.

In line with this orientation, the Bureau favors general health
courses with emphasis in one or another specialty for health .
workers rather than concentrated courses in a given specialty.
Tuberculosis, venereal disease, and maternal and child health wor-
kers, should all have formal training in public health.

Although fellowships for study in the more advanced institu-
tions of the United States and Canada must continue for some time
to be an important part of the training of the leaders in public
health in the Americas, Latin American institutions and services
have advanced to the point where they are being increasingly used
in the training of Latin American workers. The advantages are ob-
vious; first, training can be in Spanish and Portuguese, and second,
the conditions of training more nearly approach those under which
the trainee will be called upon to apply the results of his train-
ing.

For limited intensive training the Bufeau has maintained a
course for seologists of Central American and Panama in Guatemala
during the past two years and is organizing similar projects for
Venezuela and Brazil. Workers in rabies have been trained in the
United States and Mexico. A two-weeks intensive course (so-called
Institute) for Hospital Administrators was organized to begin June
18 in Brazil and a work shop for nursing supervisors in Chile,
July 10.
-49-

13- Restrictions on the Bureau's Activities

Although a liberal interpretation of the Pan American Sani-
‘tary Code and of the Constitution of the Pan American Sanitary
Organization would place practically no theoretical restrictions
on the activities of the Bureau in the field of preventive medi-
cine, medical care and the medical sanitary aspects of social
welfare, the size of budget and staff do establish practical
limits. ,

As a general principle the Bureau should not duplicate the
activities of other organizations nor should it do for a Member
State those things the State is best fitted to do for itself.

The Bureau should attempt to supplement existing services rather
than substitute for them. The Bureau should not become involved
in heavy capital investment in buildings, (except possibly for
the permanent headquarters for the Bureau itself) nor in water
supply and sewerage projects which, by their very nature, require
substantial financial outlays.

The Bureau must maintain its position as a source of techni-
cal rather than financial aid to Member States. ‘The Bureau should
not participate financially in routine health programs except as
it may be necessary to do so for the study of administrative
techniques, the development of new methods or the demonstration
of known methods under local conditions.

The Bureau aids in the purchase of supplies for Member States
but it 1s not a source for supplies except in emergency or catas-
trophic conditions and then only for inmediate emargency medical
and public health materials. And in such cases the Bureau anti-
cipates repayment except in those cases in which, in the opinion
of the Executive Committee, the effect of the emergency has been
a severe blow to the national economy.

The Bureau collaborates in certain international conferences
and other meetings but cannot be expected te pay the expenses of
national representatives to such meetings.

The Bureau, in its character of coordinator of regional and
area pro jects,at times cannot accept the suggestion of national
authorities as to the timing of collaboration on different pro-
jects.

The Bureau must be free to suggest in the name of other Mem-
ber Governments in the region, that specific programs be conducted
which may not be of immediate interest to the individual country
itself. Although a country may be reluctant to undertake an
eradication or control program within its territory, in the
belief that other more pressing problems should receive priority,
cooperation with the Bureau usually follows when the importance
of the proposed project to neighboring countries is understood.
-50-

By its very nature, the Bureau performs its functions on
& non-political basis. Its dominant concern is the health
and welfare of the entire continent and it seeks to achieve this.
' goal in an impartial, objective manner. No member of the staff
may interfere in the economic and political affairs of any Mem-
ber Government and the Bureau avoids by all possible means
interference from without. The Bureau does not make salary
payments to persons not openly employed as part of its staff or
on programs sponsored by the Bureau.

The Bureau should not be expected to accept a proposal merely
on the basis of the small amount of money involved. The determining
factor in the choice of projects, as between a series of small com~
mitments and a smaller number of large commitments, should be the
relative importance of the proposed projects themselves. Projects
should not be accepted merely because they are cheap, nor rejected
because of cost. Nor should the Bureau refuse to enter into long
range programs where such are needed.

1. Collaboration with National Health Authorities

It must be the aim of the Bureau at all times to work with
existing official health services and to strengthen them rather
than to develop independent programs. When the Bureau's in-
_terests in any field lead to collaboration with the departments
of Government, the Bureau should work always with and through
the National Health Authorities. This is especially important
in the problems which are not necessarily entirely public health
problems such as statistics, the zoonoses (rabies, brucellosis
and hydatidosis) and, in certain countries, maternal and child
welfare.