4 0oI 0-year Evaluation of the Bilateral Health Programs, Institute of Inter-American Affairs

Principles of Public Health Program PlanningAnd Their Application in Latin America

Dividends are higher from any well-conceived operation, whetherby business or government. Especially in public health under-takings, where outcomes are not easily measurable, is advanceplanning essential. Here the evaluators describe certain basicprinciples and the facts and figures necessary for complete programplanning, and strike a balancecooperative programs.

THE PLANNING that had gone into 10years of operation of the bilateral health

programs of the Institute of Inter-AmericanAffairs was examined and appraised on the ba-sis of the following general considerations:

1. Program planning is one of the most im-portant functions of management, whether theenterprise be in the field of business, govern-ment, or philanthropy.

2. Experience has shown that the benefits ordividends from operations vary directly withthe quality of planning. Poorly conceived plansgiving a minimum of benefit usually call for theexpenditure of just as much effort and funds intheir execution as do good ones.

3. A business enterprise is established pri-marily to make money, and when dividends de-

This is the eighth in a series of excerpts from thePublic Health Service's evaluation of a decade ofoperation of the Institute of Inter-American Affairscooperative health programs. Background informa-tion on the evaluation survey and on the origin andstructOre of these programs can be found in the Sep-tember 1953 issue of Public Health Reports,beginning on page 829.

from the record of inter-American

cline or cease, search is immediately made todetermine what is wrong. No such automaticcriterion exists to test the efficiency of social or-ganizations such as government and philan-thropy; therefore, management of these organi-zations calls for a very highly developed senseof responsibility and critical self-evaluation.

4. By definition, a program is a prearrangedplan. Also by definition, a plan is an arrange-ment of means or steps for the attainment ofsome objective. Thus, if the objective is notclearly defined, the arrangement of appropri-ate means or steps to achieve it will be diffi-cult, and the program will lack precision andcompleteness.

Institute Program ObjectivesThe program of the Institute of Inter-Amer-

ican Affairs had more precise objectives duringits earlier years than in more recent ones. Atthe time of its establishment, the objectiveswere: (a) to improve health conditions in stra-tegic areas, particularly with relation to the re-quirements of the Armed Forces of the UnitedStates and those of its American allies; (b) tocarry out the obligations of the United StatesGovernment assumed by it under the resolution

Public Health Reports132

regarding the health and sanitation problemsof the Americas which had been adopted by theThird Meeting of Ministers of Foreign Affairsin Rio de Janeiro; (c) to make possible in-creased production of critical materials in areaswhere bad health conditions existed; and (d)to demonstrate by deeds as well as words thetangible benefits of democracy and to win activesupport of the civilian population.The first three of these objectives were inti-

mately related to the war effort, and the successin achievement could be measured objectivelyby the health records of the Armed Forces per-sonnel stationed in the Latin American Repub-lics and by the rate of production of critical ma-terials. However, even though the primaryaims were to meet an emergency need, there wasa constant interest in long-range projects look-ing toward improvement of conditions in thehemisphere. Nonetheless, the program in theearly years must be viewed as a part of the wareffort and evaluated on that basis. A highlycreditable level of achievement was attainedduring this period.After the Second World War these objectives

were replaced by others. In the Institute ofInter-American Affairs Act of 1947 (PublicLaw 369, 80th Cong.), which authorized the con-tinuance of the Institute, it was stated thatthe purposes of the Institute should be "tofurther the general welfare of, and to strengthenfriendship and understanding among, the peo-ples of the American Republics through col-laboration with other governments and govern-mental agencies of the American Republics inplanning, initiating, assisting, financing, ad-ministering and executing technical programsand projects, especially in the fields of publichealth, sanitation, agriculture and education."In line with this directive the Institute de-

clared that the broad, basic objective of its post-war program would be to raise the level ofliving of the people in the several AmericanRepublics, and it viewed this objective as withinthe framework of a larger one-peace and pros-perity in the Western Hemisphere.Thus, postwar objectives were general, and

evaluation of success in attaining them wastherefore more difficult. The task was furthercomplicated by the fact that many forces wereat work, striving to achieve the very same ob-

jectives. Since the survey was concerned withonly one part of the Institute program-healthand sanitation-the following criteria were es-tablished for measuring success: (a) the ex-tent to which the indigenous health organiza-tions were being developed and stabilized; (b)the rate at which programs and methods werebeing incorporated into the permanent publichealth structure; and (c) the extent to whichhealth habits and practices of the people werebeing influenced.

Responsibility for PlanningThe program in each country had to be di-

rected toward the achievement of the broad ob-jectives set forth in the basic agreements be-tween the United States Government and thegovernment of the host country. The respon-sibility for preparing a detailed plan of oper-ation was shared by the minister of the unitof the host government in which the Serviiaowas established and the chief of the UnitedStates field party, who was usually also the di-rector of the Servicio.Program planning ranged from excellent to

mediocre. There appeared to be a direct cor-relation between excellence of planning and thenumber of years a Serv?m,o director had beenin a given assignment. In several countriesit was observed that the program had changedwith each new chief of field party; therefore,the value that might be expected from prolongedintensive efforts was dissipated. Often plan-ning was lost sight of in the pressure of dis-charging operational responsibilities.In one country the program during the initial

period resulted from dictation rather than jointplanning. Instead of the appropriate type ofprogram being determined on the basis of astudy of the country's needs, it was determinedex cathedra by the minister and other high gov-ernment officials. Ten new hospitals were builtand 17 existing ones received substantial addi-tions to their facilities. At the time of the fieldsurvey in late 1951, 3 of these new hospitals werestill not in use. This was an example of poorplanning, or more accurately, of no planning.

Foundation of Good PlanningA knowledge of certain basic facts concern-

ing a country and its people is considered nec-

Vol. 68, No. 11, Noveember 1953 1133

essary for sound program planning. Charac-teristics of the population, vital statistics,health institutions, health personnel, govern-mental structure, voluntary health agencies,social institutions and customs, economic sta-tus, and geography and climate are among theareas in which data should be obtained.An increasingly active interest in program

planning was found during the field survey inLatin America. Where the basic facts wereincomplete and inadequate, steps were beingtaken to supplement them. It is recognized, ofcourse, that the collection of basic data is a longand laborious task and that certain of the datawill have to be kept current. Rarely will thedirector of the Servicio be able to accomplishthe task by himself. The talents of all fieldparty members and of many members of thenational health service will have to be enlisted.A continuing responsibility for collecting andassembling basic data might well reside in aspecial committee appointed by the director ofthe Servicio.

Populatio'n CharacteristicsThe geographic distribution of the people is

likely to have a direct bearing on the type ofdisease burden and the ease with which the peo-ple can be reached in a program for health bet-terment. If the population is predominantlyrural, the problem of establishing contact be-tween the people and the health service willtax the administrator's ingeniousness, and thisproblem will be even greater if the rural popu-lation lives on scattered farms rather than invillages.The age level of the population will indicate

whether the program should be directed pri-marily toward the health hazards of infancy,youth, and early adult life or toward the dis-eases that characterize old age.The principal occupations should be known

since certain occupations have intrinsic healthhazards. The lumberjack in the endemic areasof jungle yellow fever, for example, is in spe-cial danger of contracting the disease. Amongcertain types of miners, silicosis may be ahazard. The factory worker from ruralareas appears to be especially susceptible totuberculosis.

Racial composition of the population should

be determined since susceptibility and resist-ance to certain diseases are known to be in someway related to race.Knowledge concerning literacy will have

value in determining the most effective meansof communication. The techniques used inhealth education, for example, will have to beadjusted accordingly.

Vital StatitstCAn accurate census is essential in every field

of social endeavor. It not only provides theinformation required to establish the charac-teristics of the population, but it permits cal-culation of rates and establishment of baselineswhich are necessary in measuring the effective-ness of health programs.The number of births, deaths, marriages, and

divorces by age and sex where appropriate andby political subdivision should be known. Aneffort must be made to determine the nature ofthe mechanism established for the collection ofvital statistics and the precision with which itfunctions; otherwise, it will be impossible tojudge the reliability of the statistics or to de-termine how they may be improved.The causes of death and, if obtainable, the

causes of illness, will help identify the princi-pal diseases of a population. Frequently, theincidence of a disease in an area, or in an en-tire country, is unknown, and just as frequentlyno mechanism for ascertaining the facts exists.In such circumstances, a sampling survey mayhave to be undertaken. The prevalence ofhookworm infestation, for example, was not ap-preciated in many Latin American countries 30years ago. Surveys revealed that hookworminfestation affected up to 100 percent of thepopulation and that actual disease occurred infrom 10 percent to 50 percent or more.Information as to the average family income

should serve as an ever-present warning to avoidactivities that call for expenditures by house-holders beyond their financial competence.

Health InstitutionsThe majority of health institutions are con-

cerned with the prevention, diagnosis, andtreatment of disease. They include the healthdepartments with their health centers, special-ized clinics, and other preventive services; the

Public Health Reports1134

laboratories for the control of water, milk, andother food products, and the diagnosis of mor-bid conditions; and hospitals of all types.Another smaller group of institutions whose

importance cannot be overestimated is the re-search group. These institutions determine inlarge measure the rapidity with which ad-vances may be achieved in medical care, bothpreventive and curative. Often, of course, theinstitutions primarily concerned with the ap-plication of medidal knowledge, such as hos-pitals, diagnostic laboratories, and healthdepartments, also engage in research. Their in-vestigations are as likely to be focused on ad-ministrative practices and organization as onmedical knowledge per se.A complete list of these several institutions

is necessary to determine whether or not theyare readily accessible to the population and towhat extent they are capable of meeting theneeds of the country.

Health PersonnelThe number and distribution of medical and

health personnel serving a population and thenature and capacity of institutions for train-ing such personnel should be determined asaccurately as possible. The number of physi-cians, engineers, dentists, dental hygienists,hospital administrators, nurses, nurse's aides,socia! workers, sanitarians, dietitians, andothel specialized workers will indicate whereexpansion of training institutions is mostneeded. The extent to which such personnel isconcentrated in urban areas, especially wheni therural population carries the principal diseaseburden, must also be known. Some estimateas to the quality as well as the quantity ofworkers in the health and medical fields ishighly desirable, though obviously more diffi-cult to determine.

Governmental StructureThe organization and the functions of each

part of the host government having a respon-sibility in the health field should be recorded.Though the ministry of health in Latin Amer-

ican countries usually carries the major obliga-tion for health services, the ministry of socialwelfare and the ministry of social security,

where tlhese exist, frequently administer a part,if not all, of the hospitals and custodial insti-tutions of a country. The ministry of educa-tion frequently has the obligation to main-tain school health services and to this extentalso shares in the administration of the na-tion's health services. This ministry's majorresponsibility in the health field, however, usu-ally concerns the preparation of medical andhealth personnel. The ministry of public worksis likewise tied in closely with the health fieldin view of its role in the construction, and oftendesign, of hospitals, health centers, water sup-plies, and sewage treatment plants.

Voluntary AgenciesA careful analysis of the programs conducted

by voluntary health agencies should be madeso that due weight may be given them in plan-ning the national health programs. The RedCross, for example, frequently operates schoolsof nursing and health centers. In a number ofcountries a large part of the campaigns againsttuberculosis and the venereal diseases is car-ried on by voluntary organizations.

Social Institutione and CustomsSocial institutions, customs, and cultural

traits are less easily identified and understoodthan the infectious diseases, for example, butthey are equally important, if not more so, inplanning health programs. The health plannerneeds to be familiar with the current beliefsof folk medicine and the attitudes of peopletoward modern scientific medicine. He musthave an understanding of the habits of the peo-ple, the motivations of individuals, and theirgoals in life. Land tenure laws, social legisla-tion, and housing are also important subjects inthis field.

EconomicsThe economic potentialities of a country, as

well as its present status, must be understoodas a basis for realistic planning and as a meansof protection against undertakings which arebeyond the national resources. The level ofproductivity, the nature of the labor market,the trend towards industrialization, the na-tional income, and the tax system are additionalmatters requiring investigation.

Vol. 68, No. 11, November 1953 1135

Education, Agricidture, and Induustry

The fields of health, education, agriculture,and industry are interrelated and interdepend-ent. If the level of living of a people is to beraised, no one of them may be ignored. Theplanner in the health field must therefore un-derstand the problems of education, agriculture,and industry and, whenever possible, shouldseek ways and means whereby the health pro-gram will aid and reinforce programs in thesefields and should attempt to utilize related pro-grams to aid the health programs.

Geography and ClimateThe geographic and climatic characteristics

of a country have a direct relationship to manyof its health problems. Not only physical fac-tors, such as altitude, latitude, soil, insolation,temperature range, humidity, and rainfall, butmany biological factors as well, are involved.The fauna and flora also determine in no smallmeasure the health lhazards of an area.

Formulation of a ProgramThe next step in program planning is to de-

termine from a study of such basic data whatthe outstanding problems of the country areand which ones are susceptible of solution. Itis at this stage of planning that the experienceand judgment of the minister and the chief offield party are of crucial importance. Theyand their advisers must assign priority valuesto the several problems calling for solution.Program formulation may then proceed.Depending upon circumstances, the program

objective may be attained by a single project,such as the installation of a water supply sys-tem, or by a series of projects, such as thoseaimed at the control of tuberculosis. In thelatter case, one project of the series might bean epidemiological study of tuberculosis to de-termine its incidence rate, the principal ave-nues of dissemination, or the role that BCG vac-cination might be expected to play. Anotherproject might be a case-finding campaign.Still another could be the establishment of atuberculosis hospital.Though projects will differ widely in their

aims and provisions, they should resemble one

another in their formulation. The projectagreement drawn up by the chief of field partyand the minister should provide the followinginformation: (a) the nature of the problemand objective of the project; (b) any previousprojects which are similar; (c) a complete de-scription of the project, including the location,the reasons for selection of the project, and themanner in which it is to be developed; (d) aclearly defined plan of administration; (e) theproposed time schedule; (f) arrangements forthe transfer of the project to the national healthservice; (g) an estimate of the amount of moneyto be spent; and (h) the sources of funds.The project agreement should be so complete

and well documented that a new chief of fieldparty or a new minister would have no difficultyin understanding the project or in discharginghis responsibilities for its successful comple-tion. The goal which the project aims toachieve should be precise and limited sothat the accomplishment may be measuredobjectively.

Evaluation of Program PlanningIn general, project agreements were found to

be well prepared. The principal shortcomingswere (a) the frequent omission of terminaldates, despite the fact that provision usuallyexisted for an extension of the date if it wererequired; and (b) the absence of arrangementsfor the orderly transfer of responsibility forthe project from the Servtcio to the appropriategovernment agency.

Planning for TranferChiefs of field party were sometimes reluc-

tant to relinquish responsibility for completedprojects for reasons that seemed unconvincing.For example, fear was expressed that a projectwhen transferred to the host government wouldnot be maintained at the same level of efficiencyas under Serviejo administration. If this fearwere supported by facts showing, for example,a lack of funds or personnel to carry on theproject, it could only mean faulty planning.Such prejudgments were regarded as neitherpersuasive nor trustworthy. The better pro-cedure would have been to try out the newadministrative auspices. If failure ensued,

Public Health Reports1136

then the reasons for failure could be identifiedand appropriate corrections applied.In one instance, the director of the Servido

declared a certain health center, which had beenin operation long enough to be considered anaccepted method for providing preventive med-ical services, to be indispensable to him as atraining center for Servimco personnel. In thisparticular country, the ministry of health hada section in its organization charged with re-sponsibility for the training of personnel, whichcould have been used to meet the ServiZoo'.,needs.An example of inadequate planning for the

final transfer of a project to the constitutedhealth authorities of the cooperating countrieswas found in one country. Although at thetime of the survey, Servicoz operations were inthe hands of Latin Americans, difficulties hadbeen encountered in transferring 'completedprojects to the national health department.What had not been done, or could not be done,was to transfer with completed projects theprivileges and immunities enjoyed by the Ser-vicio but denied to the national health depart-ment. By virtue of the basic agreement be-tween the ministry of health and the Institute,the Serviaco had relative freedom to hire andfire personnel and was exempt from many bu-reaucratic controls on administration and utili-zation of funds. The national health depart-ment, recognizing its inability to equal theeffectiveness of the Sevicio, had therefore beenreluctant to assume responsibility for certainof the major health and sanitation projects. AServiejo responsibility for many years, theseservices should be relinquished; yet, it appearsthat for the present the Servicio will be requiredto continue their operation.

ConclwsionThe indigenous health organizations in Latin

America usually, but not invariably, have beendeveloped and stabilized as a result of theServiejo projects. More attention to planningmight well have mitigated some shortcomings,however.The rate at which programs and methods

were incorporated into the permanent publichealth structure has been generally satisfac-

tory, although incomplete planning sometimeshas retarded the process.Although the extent to which health habits

and practices of the people have been influencedis difficult to evaluate precisely, many of thesituations studied indicate that the people'shabits and practices were, in fact, favorablyinfluenced.

National Advisory Health CouncilsA survey of health program planning cannot

be limited to planning done by the Servicio8since health programs in Latin America are forthe most part formulated and executed by theconstituted health authorities of the national,state, and local governments. In some coun-tries private agencies play a major role inhealth activities. In almost all the countries,the Red Cross conducts a health program thatsupplements that of the government.In certain countries the entire campaign

against tuberculosis is the responsibility of aprivate or voluntary agency. Notable in thisregard is the Liga Ecuatoriana Anti-Tuberm&-losa which maintains in various parts of thecountry 23 dispensaries and 8 hospitals with atotal of 2,000 beds. Not infrequently the hos-pitals, or a large portion of them, are operatedby a voluntary organization termed Beneficen-cia. These voluntary agencies are usually sub-sidized by government, and in addition theybenefit from lotteries or special taxes authorizedby government.

Because the ultimate responsibility for allhealth programs rests essentially with the gov-ernment, considerable advantage could resultfrom joint planning. Moreover, since the suc-cess of health programs, whether official or vol-untary, depends to a considerable extent uponan alert and informed public, it would appeardesirable for the public to be brought into a re-lationship with the official planners.A mechanism to secure both the benefits of

coordination and of broad public support ofhealth programs would be a national healthcouncil, advisory in character. Such a councilcould be created by the ministry of health.Membership should include representativesfrom all the national agencies concerned withhealth, the voluntary organizations, the uni-

Vol. 68, No. 11, November 1953 1137

versities, and the technical schools, as well aspersons from philanthropy, business, finance,and industry. The council's membership wouldthus represent a cross section of society of thenation and would embrace the planners, pro-viders, and consumers of health programs.The advisory character of the council should

be maintained. It should have no executive,financial, or administrative responsibilities.However, because of its composition, its adviceshould carry great prestige. Health plans ofgovernment might thereby be greatly strength-ened.In countries where governments may on oc-

casion change suddenly, a national advisoryhealth council would have the added value ofproviding a link between the old and the new,giving greater continuity to health activities,especially planning.

National and International ConferencesA number of agencies in addition to the In-

stitute of Inter-American Affairs are engagedin cooperative health programs with many ofthe governments of the American Republics.Important ones are the Pan American SanitaryBureau, which serves as the regional office ofthe World Health Organization; the UnitedNations Children's Fund; the Kellogg Founda-tion; and the Rockefeller Foundation.The interests of these several agencies are

not so very different, one from the other, andtheir cooperative programs in the AmericanRepublics are in consequence closely related.In Chile, three of these agencies-the KelloggFoundation, the Rockefeller Foundation, andthe Institute of Inter-American Affairs-co-operated with the government in the develop-ment of nursing education and medical educa-tion. The latter two agencies worked with thegovernment in establishing the National Schoolof Public Health in Santiago.The National School of Nursing of the Cen-

tral University in Quito, Ecuador, is anotlherexample of joint action. The PASB, the IIAAand the Rockefeller Foundation joined forcesin aiding the Ministry of Health in the develop-ment of this institution. Aid included the pro-vision of two Americani niurses to help with

organization and guidanice in the early years,the reconstruction of a building to house theschool, the purchase of equipment, some as-sistance in the initial cost of operation, andprovision for a consultation service.In almost every Latin American country ex-

amples could be cited of participation by morethan one of these agencies in the national healthprogram. The fact that so little real overlapand duplication of program activities was ob-served is a tribute to those responsible locally.However, it must be recognized that there isa degree of competition among the agenciesto secure cooperative projects and funds tofinance them, with the consequent danger ofadverse effect upon the national health budget.

It would be a part of good planning for thesecooperating health agencies and the several na-tional health services to adopt some device forprotection against possible adverse effects fromuncoordinated program developments. Moreimportant would be the positive benefits thatcould accrue from the application of the jointresources in technical skills and funds towarda common objective. To this end, it is sug-gested that clearinghouse conferences be estab-lished at both the international and nationallevels. At these conferences an opportunitywould be provided each agency to describe itsprogram interests and its plans for project de-velopment. Opportunities, if any, for jointaction would become apparent.A beginning at the international level has

already been made in Washington, under thechairmanship of the director of WHO-PASB.Monthly meetings are being held with repre-sentatives from PASB, the IIAA, the Divisionof International Health of the Public HealthService, and other agencies. These have al-ready proved useful.A similar arrangement seems desirable for

each American Republic where more than oneforeign agency is cooperating. Since all inter-national health agencies enter into bilaterialagreements with the various governments in de-veloping programs, the leadership in establish-ing clearinghouse conferences at the nationallevel should be taken by the health authorities ofeach country.

Public Health Reports1138

Fifty-first Annual Confer.ence of the Surgeon' Gen-eral, Public Health Service,Chief, Children's Bureau,With State and TerritorialHealth OfficersPublic Health Service PublicationNo. 307. 1953. 75 pages. Availableon request to the Division of StateGrants, Public Health Service, Wash-ington 25, D. C.

The fifty-first annual conferenceof the Surgeon General, PublicHealth Service, and chief, Children'sBureau with the State and Terri-torial health officers, State mentalhealth authorities, and representa-tives of State hospital survey andconstruction agencies was held De-cember 8-11, 1952, in Washington.This publication constitutes the pro-ceedings of the conference and in-cludes the complete text of addressesgiven in the general sessions and therecommendations of the committeeson environmental sanitation, Fed-eral relations, hospitals, infectiousdiseases, maternal and child health,mental health, and special healthand medical services. [Highlightsof major addresses were publishedin Public Health Reports, February1953, pp. 174-190.]

Health ManpowerSource BookSection 2. Nursing PersonnelPublic Health Service PublicationNo. 263. 1953. Prepared by HelenG. Tibbetts and Eugene Levine. 88pages; tables. 40 cents.

The second in a series of compre-hensive source books on health man-

Power, this publication covers 50ears of nursing and contains 56ables of data on nursing personnel,bach preceded by a discussion of thebackground and methods used togather the data.

The first part of the book dealswith the general distribution of pro-fessional nurses; their age, sex, andmarital status; licensure; and edu-cation. The second part presentsdata on the licensure and trainingof practical nurses. The last partof the book, fields of practice, givescomparative data for six fields ofnursing and details on public health,industrial, and hospital nursing per-sonnel.A summary of trends is given at

the beginning of the book. As of1950 there were 249 active graduatenurses per 100,000 population in theUnited States. In 1910 the ratio was55 per 100,000. In 1920 active grad-uate nurses were fewer than physi-cians; since 1930 they have outnum-bered physicians. Since 1900 theproportion of men among activegraduate and student professionalnurses has declined from 6 percentto 2 percent, although their numberhas increased from 758 in 1900 to11,329 in 1950.

Home Accident PreventionA Guide for Health WorkersPublic Health Service Publication No.261. 1953. 75 pages. 30 cents.

Accepting the thesis that the ma-jority of home accidents can be pre-vented, this booklet presents an out-line and guide to enable health work-ers to study and understand the chiefcauses of accidents in the home andto take measures that may preventthem. The material is prepared forthe professional health worker onthe premise that leadership in homeaccident prevention program devel-opment should be assumed by thisgroup.The problem of home accident pre-

vention is defined in relation to otherhealth needs. Factors, environmen-tal and human, tending to cause ac-cidents and their interrelationshipsare outlined. Suggested activities byagency, group, or individual for bet-ter understanding and treatment of

the problem are presented through-out the guide.A 20-page list of selected refer-

ences, coded to designate the variousclassifications of the content mate-rial, and a 2-page list of ilms andfilmstrips are Included.

Six Food Exchange Listsfor Variety in MealPlanning

Public Health Service PublioationNo. 326. 1953. 4-fold leaflet. Avail-able on request to Division of ChronicDisease and Tuberculosis, PublicHealth Service, Washington 25, D. C.

Selection of a varied diet, espe-cially for the diabetic person, Ismade easier by the use of the sixfood exchange lists developed bycommittees of the American DiabetesAssociation and the American Die-tetic Association, in cooperation withthe Public Health Service. The leaf-let sets forth six.lists of food items-milk, vegetables, fruits, bread, meat,and fat. All foods within the samelist contain approximately equalamounts of carbohydrate, protein,fat, and calories, and thus one foodin a list may be substituted for an-other food on the same list. For ex-ample, on list 4 one small potato maybe used in place of a slice of bread.

This leaflet does not give a dietprescription. A physician shouldprescribe the amounts of food andthe number of exchanges allowedeach day. The food exchange listsfacilitate selection of a variety offoods for a diet that is being fol-lowed.

Publications for which prices are quotedare for sale by the Superintendent of Docu-ments, U. S. Government Printing Office,Washington 25, D. C. Orders should beaccompanied by cash, check, or moneyorder and should fully Identify the publica-tion (including its Public Health Servicepublication number). Single copies ofmost Public Health Service publicationscan be obtained without charge from thePublic Inquiries Branch, Public HelthService, Washington 25, D. C.

Vol. 68, No. 11, November 1953 1139

technical publications

Training Courses in Prothrombin Time DeterminationsClinical research during the past decade has shown that the proper

use of anticoagulant drugs can reduce morbidity and mortality fromthrombosis and embolism. Safe and effective use of these anticoagu-lants, however, requires a more complete laboratory control than isnecessary for most drugs, since their safe administration depends uponreliable laboratory data for control of the dosage.

Refresher courses in this technique are offered by the heart section,Division of Chronic Disease and Tuberculosis, Public Health Service,with the sponsorship and/or cooperation of the various State healthdepartments, American Heart Association, pathology societies, andother interested organizations. The purpose is to present to medicaltechnicians the critique of performing accurate, reproducible pro-thrombin time determinations, and to afford an opportunity for super-vised laboratory experience with these methods.

Services and materials available through the regional offices of theDepartment of Health, Education, and Welfare include a brief descrip-tion of the course; services of a physician-director and a technician-instructor in planning and conducting the training course; a teachingmanual; and laboratory manuals for participants.

Since the pilot technician-training program began in Massachusettsin 1950, refresher courses have been provided in 12 States and 1 Terri-tory (see table). In at least 9 other States, technician-training is nowbeing provided on a long-range basis by local institutions.

Number NumberNum- labora- Num- laboraber treorber

State tech- treorState tech- tories ornicians hospitals nicians hospitalstrained repre- trained repre-sented sented

'Arkansas-22 16 North Carolina_. 47 38Florida ------ 88 64 South Carolina- 14 11Idaho 6 5 Tennessee- 10 8Kansas- 28 26 Utah- 23 13Maryland_-- 1 1 Puerto Rico- 15 11Massachusetts- 71 55_Montana- 15 9 Total 366 279New Jersey- 26 22

NOTE: At the time this table was prepared, a series of courses was being givenin Virginia to about 18 technicians.

Pubic Hieaith Reports1140