|Disasters Preparedness and Mitigation - Issue No. 18 - January, 1984 (PAHO)|
In compliance with Resolution VII of the twenty-seventh meeting of health ministers of Central America and Panama (REMCAP) (see Newsletter No. 10), a meeting was held in Guatemala from December 5 to 7, 1983, to evaluate progress of national disaster preparedness plans in member countries. The delegates - from Costa Rica, El Salvador, Guatemala, Honduras and Panama - reviewed the following areas:
- National programs for health preparedness; their legal aspects, organization and financing, and inter and intrasectorial coordination.
- National activities in environmental sanitation and engineering preparedness.
Among the most important recommendations approved unanimously are:
· Full implementation of Resolution VII, especially regarding the creation of technical units in the health ministries that will be responsible for overall disaster preparedness in the health sector.
· The need to foster cooperation between countries of the Central American subregion.
· Recommend to the governments represented that they request the inclusion of the subject of disaster preparedness in the agenda for discussion at the next PAHO Directing Council meeting.
· Ratification of the support of the subregion for continued development of disaster preparedness activities, through a new resolution to be presented at the next REMCAP meeting.
· Inclusion of training and public awareness activities in national programs.
· The need for periodic meetings to evaluate national and regional progress in this area.
· Inclusion of the subject of disaster preparedness in continuing education programs for in-service health personnel.
This article was written by Enid G. Harden, PAHO Nursing Adviser and Hilda Filinich de Zegarra and Gladys Zárate León, President and member, respectively, of the Scientific Commission of the Peruvian School of Nursing.
Nurses will be involved to one degree or another when a disaster occurs. At times, her or his role will be critical. To perform efficiently, the nurse must be prepared to change plans of action at any time and adapt to new situations, be a planner, health educator, care provider, administrator, intervene in crises and, sometimes, manage triage.
It is therefore necessary to prepare the nurse at undergraduate and graduate levels. We consider the minimum basic course requirements to be: first aid, cardiopulmonary resuscitation, psychological crises intervention, triage and protocols for nursing care.
In November 1982, the Peruvian School of Nursing and the Pan American Health Organization held a workshop on the "Role of Nursing in Emergency and Disaster Situations." The objective was to prepare nurses for a greater participation in the management of disasters such as earthquakes, floods, droughts and landslides which occur relatively frequently in Latin America. Throughout history these natural hazards have caused a great number of victims and social and economic consequences.
The following main conclusions and recommendations emerged from the work groups and plenary sessions:
1. That tire nursing departments of each health institution have an emergency nursing plan for disasters winch is compatible with the institutional plan and with Civil Defense plans for the health sector.
2. Given the importance of nursing in disaster situations, nurses should be represented on the multidisciplinary and multisectorial committees set up to develop general disaster plans.
3. The tasks of nurses In disasters and emergency situations are:
Planning: prepare action plans for nursing according to community risks; maintain up-to-date inventories of community resources; organize disaster simulation exercises, and elaborate emergency nursing protocols.
Administration: organize nursing teams according to area of responsibility; identify nursing staff and supply needs according to local conditions; coordinate nursing activities with the larger health team and other sectors, and set up logs and nursing reports for emergency and disaster situations.
Care: participate in triage; provide nursing care according to established protocols, and manage emotional crises of patients in coordination with other health team members.
Teaching: develop courses on disasters for nursing personnel and the community.
Research: participate in epidemiologic surveys after disasters and carry out operational research on the effects of disasters on the health of communities and ways in which to reduce the impact through nursing care.
4. Include a content area and case studies on disasters in course materials of nursing schools, in order to train nurses to carry out the above tasks.
5. Develop post-graduate courses of the same nature to enable nurses to take on even more complex tasks in times of emergency.
6. Elaborate nursing protocols that serve as guidelines for their functions in times of disaster or emergency. Six -preliminary protocols were already sawn up during the workshop, for care of burns, exposed fractures, uninfected open wounds, pyschological crises, asphyxia and hemmorhage.
Concern about nursing care in disasters is not limited to Peru. The National Social Security Institute of Ecuador has field three workshops on health sector preparedness for disasters which included hospital directors and administrators as well as nurses. In Barbados, a workshop similar to the Peruvian one was held to carefully analyze the role of nurses in disasters.
Note from the Editor:
Nurses are a vital part of the health team and often are its only representative in the community. Their training for emergencies and disasters is hence crucial. It is well worth considering the inclusion of such subjects as epidemiologic surveillance after disasters, national disaster plans, hospital planning for internal and external emergencies, management of nutrition and feeding programs, mass casualties, triage, and other related areas, in the regular training curriculum of schools of nursing. PAHO is willing to lend technical cooperation, as resources permit, to schools of nursing and other institutions that are interested in developing such a program.
We publish the following abstract of a letter in the hopes that those of our readers who have information and experience in this area will contact the author. When writing, please do so through Dr. Jones, WHO/EURO, 8 Scherfigsvej, Copenhagen, Denmark.
On October 30, an earthquake of 7.1 magnitude occurred in the eastern provinces of Erzurum and Kars. This is a cold mountainous region. The winter temperature falls below -35C. Construction is for this reason made of broken stone joined by a plain mud paste that does not have a good sealing quality. The roofs are supported by fragile posts of native wood that are imbedded in the walls of the houses, some of which are up to 60 to 80cms thick. The roofs are flat, and made of local clay, with a thickness of 1.5m or more to provide protection against the cold.
This kind of construction naturally collapsed, causing the death of 1333 persons, leaving several thousand injured and 35,000 homeless. Material damages were heavy in 115 shepherd villages where approximately 25,000 head of cattle and sheep were lost, in addition to the destruction of housing and human and animal food stocks.
I am interested in technologies for housing construction that make use of local materials but will ensure greater structural safety. I would like to request that through you, I might come in contact with persons who have experience in this field, in order to better assist the government of Turkey in the reconstruction effort.
José Oltio Espinoza
WHO Sanitary Engineer
PHC Project Coordinator
PK 235, Yenisehir
20-24 February, Suva, Fiji. Course on health aspects and relief management of natural disasters, for 17 countries of the Pacific Islands. Sponsored by WHO office for the Western Pacific Region and WHO Emergency Relief Office with the assistance of the WHO Collaborating Center for Disaster Epidemiology. For information, write: Attention Dr. S.W.A. Gunn, WHO/FRO, 20 Avenue Appia, 1211 Geneva 27, Switzerland.
Disaster preparedness and recovery management, Oxford Program of Development Workshops, 30 April to 15 June. Will cover hazard resistant building, refugee management, relief management, disaster preparedness and local training programs. Write: Ian Davis, Department of Town Planning, Oxford Polytechnic, Headington, Oxford OX3 OBP, England.
Sixth biannual meeting of the management committee of the Pan Caribbean Disaster Preparedness and Prevention Project, tentatively scheduled to be held in Santo Domingo, Dominican Republic. For further information, write: PCDPPP, P.O. Box 1207, St. John's, Antigua, W.I.
Technological Disasters, Toluca, México. Will cover a theoretical approach to planning, case studies, a protocol for retrospective studies and vulnerability profiles of countries in Latin America and the Caribbean. Collaboration effort of the Pan American Center for Human Ecology and Health and the WHO Global Program for Chemical Safety. Write: Dr. Jacobo Finkelman, ECO, Apartado Postal 37-473, 06696, México, D.F., México.
Second International Congress in Israel on Disaster Management, Jerusalem, September 16-18. Investigators are invited to submit abstracts no later than March 30, on the following topics: organization, planning, management, education, prediction and mitigation, socio-psychological aspects and diagnosis and treatment of casualties. For further information, write: P.O. Box 50006, Tel Aviv 61500, Israel.
International Aeromedical Evacuation Congress, September 10-14, Zurich, Switzerland, covering air rescue services, aeromedicine, material and organization and operation. Also, exhibit of aeromedical technology. Write: Organizer, Swiss Air Ambulance (REGA), Dofourstrasse 43, CH-8008 Zurich, Switzerland.
At a meeting held from November 28 to December 2, 1983, the directors and curriculum coordinators of the schools of public health of Latin America and the Caribbean spent two days reviewing training materials prepared by the Pan American Health Organization for disaster preparedness activities.
The delegates to the meeting spent a day going through an earthquake simulation exercise, after which they reviewed manuals and slide programs on the subject. On the third day, the curriculum coordinators met to discuss the relevance of the materials to their teaching curriculum, and how they would like to proceed with including this new area in the core content area for degrees in public health.
The group reached its conclusions by unanimous decision and recommended them to PAHO. Among others, these included:
1. To include the subject of disaster preparedness in the plan of studies for health administration. The adaptation of the material should also be considered for undergraduate programs.
2. The subject matter should be taught as an independent and integrated part of the study plan
3. A person should be designated to be responsible for this study unit, according to the organizational structure of each school, institution or department. Teaching should be done in an integrated fashion, with the participation of professors from the various disciplines involved (administration, epidemiology, environmental sanitation, etc.)
4. The duration of the unit should be of approximately 15 to 30 hours.
All the schools represented indicated that they would like to begin teaching disaster preparedness as an integrated part of the curriculum in 1984, during which year they recommended that PAHO maintain follow-up activities. A meeting to evaluate progress and share experiences is tentatively scheduled for early 1985.
A limited number of copies of the final report, conclusions and recommendations and background documents for the meeting are available (in Spanish) from the Editor of this Newsletter.
Brazil: Disaster preparedness curriculum
The Faculty of Public Health of the University of São Paulo is scheduling the inclusion of disaster preparedness in its curriculum. Tentatively scheduled for mid-year, the course would concentrate on health effects and management of foods and drought. As a first step, faculty members will take part in a workshop on the subject with local personnel who have had disaster experience. For further information, write: Dr. Ruy Laurenti, Av. Dr. Arnaldo 715-01255, São Paulo, SP, Brazil.
Colombia: SENA reconstruction program in Popayan
The national training service of Colombia (SENA) undertook a housing reconstruction program after the March 1983 earthquake destroyed or damaged 72% of the houses in Popayan. The SENA program is part of a self-help reconstruction program which organizes low-income earthquake victims into groups of 15 families and then trains them in construction techniques to increase seismic resistance. After several courses, model house repair demonstrations were made for brick and adobe houses for urban and rural settings. The techniques employed may be of great interest to other earthquake prone countries with similar local materials and housing construction. Illustrated booklets were prepared for the project in collaboration with INTERTECT, a LIS-based group of architects specializing in disaster mitigation. For further information on the SENA project, write: Dr. Gustavo Wilches-Chaux, SENA, Apartado 623, Popayán, Colombia.
Haiti: Disaster Organization created
The Government of Haiti recently enacted a law creating the Pre-disaster and Relief Organization (OPDES), an "autonomous public organization (...) under the Department of Public Health and Population. OPDES is responsible for the "coordination and harmonization of the activities of the public and private sectors and nongovernmental and external cooperation agencies in order to be prepared for natural and other disasters, to plan and organize relief efforts in case of any disaster causing death and injury within the population or the complete or partial destruction of public services and private properties, and causing damage to basic infrastructures and therefore requiring urgent measures for the protection and safety of the victims and the rehabilitation of those infrastructures." As part of preparing for disasters, the law envisions carrying out inventories of resources, developing plans for all sectors under a National Plan, and suggesting administrative measures to strengthen prevention measures. Copies of the law enacting OPDES may be obtained (in French or English) by writing: Department of Public Health and Population, Port-au-Prince, Haiti.
Honduras: National health plan for disasters
Honduran delegates to the meeting of health ministers of Central America and Panama presented the National Health Plan for Disasters recently approved in that country. The Plan is written as a working document for easy reference in emergencies. After briefly describing the history of disasters that have affected Honduras, the Plan lays out the health sector's organization, lines of authority and functions by level, guidelines for the alert, emergency and rehabilitation phases, and preliminary assessment of needs. For further information, write Ministry of Health, Tegucigalpa, Honduras.
Jamaica: Trainers' workshop
Curriculum coordinators from the schools and programs of public health of Jamaica will hold a meeting from February 2 to 5 to prepare a final standardized curriculum for teaching disaster preparedness to health professionals. The meeting was scheduled in October at which time the same people gathered to develop a core content area, review materials prepared for the purpose by PAHO, and discuss the roles of various health disciplines in disaster preparedness and relief efforts. The University of the West Indies School of Social and Preventive Medicine, among others, has already begun a teaching program in this area.
Mexico: Preparing for chemical emergencies
The Pan American Center for Human Ecology and Health (ECO) is finalizing a vulnerability profile of the American Region regarding health risks posed by chemical emergencies. The profile is based on a breakdown of major industries, employment patterns and transport and storage of chemicals. When completed, the study and reports of several country experiences will serve as the basis for discussion in a meeting of selected Latin American and Caribbean nations to be held at ECO (see Upcoming Meetings). The WHO Global Program on Chemical Safety will cooperate closely in the organization of the meeting. These activities are aimed at the development of long-term planning for prevention and mitigation of public health emergencies following chemical accidents.
Mexico: Relief activities carried out by the Social Security Institute after the eruption of the Chichonal volcano
The General Medical Division of the Mexican Social Security Institute has prepared a report on the "system of integrated health care for the population affected by the Chichonal volcano," 1982. The volcano, located on the border of the states of Chiapas and Tabasco, caused serious damage to surrounding settlements and the displacement of the population to nearby cities. The document, prepared by Dr. Felipe Cruz Vega, describes the results of a survey aimed at determining the health conditions of the population and the relief measures that were taken by the Institute. For space reasons, the report cannot be published in this issue of the newsletter, However, interested readers may obtain a summary from the Editor (see Selected Bibliography). The full report may be obtained by writing: Instituto Mexicano del Seguro Social, Avenida Cuautemoc 330, Edificio A, Subdirección General Médica 6° Piso, México. D.F., México.
Nicaragua: Disaster preparedness in health
The National University of Nicaragua has included the subject of public health in the event of disasters in its curriculum for training health professionals. Topics covered in 40 hours of class time and field practice include types and effects of disasters, medical care and organization of health services, community participation, epidemiologic surveillance and control and environmental health in the event of natural disasters and warfare. National and international case studies are used. For further information, write: Centro de Investigaciones y Estudios de la Salud (CIES), Ministerio de Salud, Managua, Nicaragua.
Panama: Disaster action plan
SINAPROC, the Panamanian National System for Civil Defense in Emergencies, was created by law in November 1982. Since then it has carried out several important activities to make civil protection during disasters a reality. In the health sector, it has made a national inventory of potable water sources and developed an outline for a Plan of Action for national and state hospital emergency management. The inventory of health sector resources and installed capacity is considered a promising step toward the future enactment of a national health plan for disasters.
Peru: Post flood surveillance
The health ministry of Peru will strengthen its epidemiologic surveillance system in the northern states of the country, which suffered repeated floods during the earlier part of 1983. The floods caused a dramatic deterioration of environmental conditions, making it necessary to declare a state of emergency and take measures to stop the accelerating increase in disease transmission already detected. High on the list of priorities are malaria, gastroenteritis and respiratory ailments, especially among children. For further information, write: Dr. Sotelo Baselli, Director General de Intercambios Internacionales, Ministerio de Salud, Lima, Perú.
India: Disaster Management quarterly
The Joint Assistance Center, a voluntary group set up in New Delhi, following the Andra Pradesh Cyclone of 1977, has issued a request for contributions to its quarterly, Disaster Management. Now entering its second year, it covers all aspects of disaster preparedness, prevention and relief management of national and international concern. For subscriptions and further information on publications, workshops and other activities, write: Narendra Kumar Jain, JAC, H-65, South Extension-1, New Delhi 110049, India.
Caribbean Project Programs its Activities
The Management Committee of the Pan-Caribbean Disaster Preparedness and Prevention Project held its fifth biannual meeting in Antigua from November 15 to 18, 1983 to review recent project activities and program its work for 1984. The Committee is composed of one representative each of the funding and executing agencies: The CARICOM Secretariat, UNDRO, the Canadian International Development Agency, USAID/Office of Foreign Disaster Assistance, European Economic Community, League of Red Cross Societies, British Development Department and PAHO/WHO. The participating countries represented were the Dominican Republic, Haiti, Guyana, and Belize. Present as observers were Antigua, Dominica, the International Telecommunications Union and project staff.
The Committee reviewed activities in the areas of preparedness and prevention, health and first aid, communications and public awareness carried out in many of the countries served by the Project.
It was agreed that, in the future, the Project should concentrate more on support for in-country activities now that the Caribbean has been sensitized as a region to disaster preparedness by workshops and seminars. It was also decided to inform all participating countries well in advance of the various program activities, to give them time to decide whether they would like to take part. It was further recommended that the health component of the project concentrate on in-country training activities with a long lasting effect.
Another important issue which was discussed during the meeting is the development of inter-regional contacts and exchange of information. In this respect a forthcoming meeting of the Pacific Islands in Fiji was mentioned. Participation of Caribbean officials is anticipated.
The next meeting is tentatively scheduled to be held in the
Dominican Republic during the first half of April, 1984, immediately following a
meeting of all national disaster coordinators from the wider Caribbean region.
The books referred to below have been abstracted from review copies received from the publisher by the Editor of this Newsletter. Except where noted otherwise, none of the books are available from PAHO. The publisher and the list price (when available) are included at the end of the abstracts for readers who are interested in purchasing the books.
Catástrofe de Tumaco, Ministry of Health, Colombia, 86pp. Extensive refs. 1983. (Spanish)
Results of a retrospective study on the health effects of the earthquake and tsunami which occurred in the southern coast of Colombia in 1979. Findings include the fact that the vast majority of those injured were hurt while in their homes, children under 5 had the lowest injury rate and persons over 55 the highest, and other health information including type of injury according to housing construction, treatment received by site and type of injury. The research was aimed at determining priority areas for future prevention and relief measures to reduce morbidity and mortality. Description of area affected and health impact is followed by survey results. Survey questionnaires used for households, hospitals, health centers and relief personnel are included.
- Dirección de Investigaciones, Ministerio de Salud, Bogotá, Colombia.
Efectos Sociales de las inundaciones en el Paraguay, Cuadernos de Pastoral Social, 165pp. 1983. (Spanish)
Prepared by the Paraguayan Episcopal Conference, presents a comparative analysis of the environmental conditions of the affected population before and after the severe floods which caused a national emergency in 1983. Describes relief programs and proposes guidelines for future relief projects based on a demographic, economic and housing analysis of the vulnerable population. Although lacking health information, the report is one of few carefully documented descriptions of the general impact of floods and relief efforts on a Latin American community.
- Paraguayan Episcopal Conference, Asunción, Paraguay.
Emergency First Aid (18 min, 16mm, color, sound, English and Spanish)
Covers basic first aid measures such as mouth to mouth resuscitation, dealing with foreign body obstructions of airway passages, and profuse bleeding. Good for community awareness and promotion of first aid.
- US$258.00. Film Communicators, 11136 Weddington Street, North Hollywood, California 91601, USA.
Fire Safety in Health Care Facilities (15 min, 16mm, color, sound, English) Illustrates evacuation procedures, functions and responsibilities of health team members, the establishment of priorities for evacuation, and various methods for loading and moving non ambulatory patients depending on the number of staff available. Useful as part of a seminar or course on hospital safety procedures and drills.
- US$138.00. Film Communicators, 11136 Weddington Street, North Hollywood, California 91601, USA
Flashover... Point of No Return (15 min, 16mm, color, sound, English)
Illustrated description of how fires behave, the effects of heat and combustion process. Case study is shown in which mistakes In fire control procedures are demonstrated. Treats specials problems of fires in hospital settings, and correct procedures to minize loss of life and equipment.
- US$175.00. Film Communicators, 11136 Weddington Street, North Hollywood, California 91601, USA.
Food Aid in Disasters, P. Glasauer and C. Leitzmann, 110pp. Extensive refs. 1983. (English, German)
Prepared on behalf of the Diakonisches Werk of the Evangelical Church in Germany, for relief workers in developing countries. Provides guidelines for selecting appropriate foods, assessing nutritional requirements and procuring and distributing food relief. Emphasizes importance of considering acceptable foods rather than those -such as milk powder- which may be in great supply in donor countries but may cause more harm than good. Thoughtful, succinct treatment of the subject.
- Diakonisches Werk of the Evangelical Church, Stafflenbergstrasse 76, 7000 Stuttgart 1, Germany.
Practical Guide to Refugee Health Care, OXFAM, 60pp. 1983. (English)
Short, succinct booklet prepared by the Medical Unit of OXFAM. Briefly discusses guidelines and criteria for assessing health needs of refugee populations. The greater part of the booklet is dedicated to practical checklists, survey techniques, guidelines for feeding and disease control programs and sanitation measures. Includes list of essential drugs and notes on critical areas for training refugee health workers.
- OXFAM Working Paper No. 2, OXFAM, 274 Banbury Road, Oxford OX2 7DZ, England.
Write in your suggestions
In 1979 the Caribbean was struck by three consecutive disasters. In April, the Soufriere Volcano in St. Vincent erupted, forcing the authorities to temporarily resettle 20% of the population to the already densely populated south. In July, floods caused extensive damage to the western parishes in Jamaica. In September, Dominica was left in a state of shock and complete destruction by Hurricane David, one of the most powerful hurricanes of this century.
In all these disasters the immediate aftermath was characterized by uncertainty and fear of communicable disease outbreaks. This report describes the experiences with setting up communicable disease surveillance systems in the Caribbean following the three disasters mentioned. The systems used were based on simple and sensitive infectious disease indicators through symptom-monitoring and the rapid investigation of reported outbreaks.
Several variations were introduced to accommodate the different circumstances that prevailed after each disaster. The surveillance systems were continued for 30 to 60 days after the disaster.
No massive outbreaks were found during the period these surveillance systems were in operation. Most of the focal outbreaks or potential risk situations detected were associated with the disaster relief effort itself.
The report, abstracted from the author's doctoral thesis, ends with a number of conclusions and practical recommendations. A summary of these follows.
1. Epidemiologic surveillance systems following disasters should be organized quickly and be creative and dynamic. The very fact of having a system, even when it does not collect all the data one would like, makes an easy flow of information possible for whomever has something to report.
2. The surveillance system as described in this report will detect outbreaks if they occur. The drawback of the system is that it can easily detect "outbreaks" where there are none.
3. All of the outbreaks detected could have been prevented by adequate disease control measures following the disaster. In fact, most of the outbreaks detected were associated with the disaster relief effort.
Regarding the overall usefulness of epidemiologic surveillance systems following natural disasters, the author states that to have the system is not enough. If outbreaks are to be prevented, the authorities who requested that the system be established must be willing to act on the information it provides.
Disaster Reports, No. 2
Available in English only. For copies, write the Editor of this newsletter.
Wisconsin University/Disaster Course Modules
The University of Wisconsin-Extension has undertaken the development of self-instruction modules on emergency health management of natural disasters. The modules, to be based on five manuals prepared on the subject by the Pan American Health Organization are intended for distance teaching and as educational materials for use in schools of public health. The project is scheduled for completion in late 1984. The University will also develop modules in other areas such as first aid and prevention and mitigation techniques, as part of its overall plan to establish a comprehensive teaching program in disaster management.
For further information, write: University of Wisconsin -Extension, attention Mr. Don Schram, 432 North Lake Street, Madison, Wisconsin 53706, U.S.A.
The publications listed in this section are articles of interest to health professionals and others responsible for various aspects of disaster relief and preparedness programs. They have been reproduced and recently added to the collection of articles available from the Editor of this Newsletter. A complete list of available reprints will be circulated to our readers periodically. When making requests, please quote the reference code listed to the left of the publication title.
An Introduction to Disaster Medicine, M.R. Dubouloz,
International Civil Defence, No. 338: 2-5, 1983.
Experiences in Medical Coverage of Airport Disasters at Logan
International Airport in Boston, N. Dudani, Aviation, Space and Environmental
Medicine: 612-618, July, 1983.
Computer Model for Simulation of Emergency Medical Systems, J.R.
Fletcher et al. Military Medicine, Vol. 144 (4): 231-235, April
Infectious Disease Problems in Indochinese Refugees, B. Dashefsky
and D.W. Teele, Pediatric Annals 12 (3): 232-244, March,
Atlantis, A Disaster Simulation Exercise for Training Purposes,
G.N. Ritchie, Emergency Planning Digest,: 2-5, January-March,
El papel de la Secretaría de Salubridad y Asistencia en los
desastres, J. Gómez Saborio, Salud Pública en México, 25 (2): 215-219,
Sistema de atención integral a la salud de a población damnificada
por la erupción del volcán Chichonal en México, (Summary), Instituto Mexicano
del Seguro Social, 1983.
Requests from the Caribbean
Those requesting articles from countries in the Caribbean may direct their requests to:
Pan Caribbean Disaster
Disaster Preparedness in the Americas is the Newsletter of the Emergency Preparedness and Disaster Relief Coordination Program of the Pan American Health Organization, Regional Office of the World Health Organization for the Americas. The reported events, activities and programs do not imply endorsement by PAHO/WHO, nor do the statements made necessarily represent the policy of the organization. The publication of this Newsletter has been made possible through financial support of the Canadian International Development Agency (CIDA).
Correspondence and inquiries should be addressed to: