Fatores de risco para a ocorrência das úlceras plantares decorrente da hanseníase de acordo com a árvore de decisão / Risk factors for plantar ulcers from leprosy according to the decision tree

Objective:To identify the risk factors for plantar ulcers in patients with leprosy.Methods:This is an epidemiological, observational, cross-sectional and analytical study. The population was composed of leprosy cases reported from 2005 to 2016. Pearson's Chi-square test or Fisher's exact test andMann-Whitney test were used for the univariate analysis, with a statistical significance of 5% (p < 0.05). In the multivariate analysis, a decision tree was elaborated using the CHAID algorithm. Results:Clinical form, degree of physical incapacity at discharge, affected nerve and the lack of insoles or adapted footwear before appearing to ulcer are risk factors for plantar ulcer. Conclusion:the need for an early diagnosis of leprosy was highlighted, as well as the efficient association of non-drug interventions with disability prevention techniques and the use of accommodating insoles and/or special shoes.

Objetivo:Identificar os fatores de risco para a ocorrência das úlceras plantares em pacientes com hanseníase. Métodos:Trata-se de um estudo epidemiológico, do tipo observacional, transversal e analítico. A população foi composta pelos casos de hanseníase notificados no período de 2005 a 2016. Para a análise univariada foram utilizados os testes Qui-quadrado de Pearson ou teste exato de Fisher e teste de Mann-Whitney, com significância estatística de 5% (p < 0,05). Na análise multivariada, foi elaborada árvore de decisão utilizando o algoritmo CHAID. Resultados: A forma clínica, grau de incapacidade física na alta, nervo acometido e o não uso de palmilhas ou calçado adaptado antes de surgir a úlcera são fatores de risco para a ocorrência de úlcera plantar. Conclusão:evidenciou a necessidade do diagnóstico precoce da hanseníase, como também da eficiente associação das intervenções medicamentosas e não medicamentosas por meio das técnicas de prevenção de incapacidade e uso de palmilhas acomodativas e/ou calçados especiais

DC-SIGN interacts with Mycobacterium leprae but sequence variation in this lectin is not associated with leprosy in the Pakistani population.

The C-type lectin DC-SIGN is involved in early interactions between human innate immune cells and a variety of pathogens. Here we sought to evaluate whether DC-SIGN interacts with the leprosy bacillus, Mycobacterium leprae, and whether DC-SIGN genetic variation influences the susceptibility and/or pathogenesis of the disease. A case-control study conducted in a cohort of 272 individuals revealed no association between DC-SIGN variation and leprosy. However, our results clearly show that DC-SIGN recognizes M. leprae, indicating that mycobacteria recognition by this lectin is not as narrowly restricted to the Mycobacterium tuberculosis complex as previously thought. Altogether, our results provide further elucidation of M. leprae interactions with the host innate immune cells and emphasize the importance of DC-SIGN in the early interactions between the human host and the infectious agents.

Current epidemiology of leprosy.

Every year around 4,00,000 new cases of leprosy occur in India and India contributes about 80% of the global leprosy case load. The prevalence of leprosy (case load per 1,00,000 population) has come down from 52 per 10,000 in 1981 to 2.4 per 10,000 in July 2004. There is no primary prevention for leprosy. Multidrug therapy is the only intervention available against the disease. As of July 2004 there were about 2,40,000 leprosy cases on record in India. There are thirteen states and union territories in India which have already eliminated leprosy. About 70% of the cases detected in India are paucibacillary which are less or non-infectious. Ever since the start of National Leprosy Eradication Programme in 1983, the number of new cases detected every year has not shown significant change. Leprosy cases are treated for 6 months or 12 months depending on whether they are PB or MB. The treatment completion rates are now found to be 85% for MB and 90% for PB. Phased introduction of MDT services has contributed to a large extent the static level of new case detection. Without complete coverage of MDT, it is difficult to achieve stable level of new case detection. Diagnostic efficiency of the staff is very important external factor influencing case detection rate. The most important factor that could have significant impact or prevalence is the coverage of the entire population with adequate MDT service.

Overcoming prejudice.

PIP: People of African descent comprise a large proportion of Brazil's population. While racism exists in the country, it is commonly denied. Most Afro-Brazilians live in poor areas, with poor health care services, sanitation, schools, and transport. Since HIV is linked to poverty, Afro-Brazilians are more affected by HIV than is the overall population. Although Afro-Brazilians contribute to Brazil's culture, they do not benefit from that contribution. Recognizing this considerable social problem, Project Araye was created in 1996 to address issues of race and HIV. Building upon religious and cultural traditions, the project is staffed by Afro-Brazilians who are knowledgeable in both health issues and Afro-Brazilian culture. Project Araye supports a wide range of diverse community leaders in linking sexual health and HIV with other health concerns which affect Afro-Brazilians such as sickle-cell anemia, diabetes, and leprosy. One important challenge has been overcoming the target population's denial of HIV and encouraging Afro-Brazilians to accept that HIV also affects them. Community leaders include religious leaders, rap musicians, artists, and other people respected by various communities. Activities include visits to samba dance schools, Umbanda and Candomble temples, and street youth groups to provide HIV-related information.^ieng

Gender issues in the elimination of leprosy in India.

PIP: Leprosy control personnel and social science researchers, including members of the Gender and Tropical Diseases Task Force, convened at the Agharkar Research Institute in Pune, India, during November 26-28, 1996, to discuss gender issues in eliminating leprosy in India. Conference participants heard and discussed the results of a study of gender differences upon the impact of leprosy conducted during 1993-96 in 4 districts of Maharashtra State. The study explored whether gender issues affect the timing and mode of detection, treatment-seeking behavior, and compliance; the impact of the disease on social, family, and personal life; and the role of the family in mediating that impact. A sharp decline was observed in the number of registered cases among women aged 11-19 years, a period coinciding with the arrangement of marriage in India, followed by a sharp increase in female cases aged 20-35, compared to the number of cases among men. Significantly fewer female cases than male cases were detected through voluntary reporting. In urban areas, sex differences in registered cases were minimal, while in rural and tribal areas, significantly more males than females were registered. While many women reported that pregnancy and childbearing exacerbated their disease, they were not informed about such risks when going for treatment. Non-leprosy health personnel were poorly trained to recognize early symptoms of the disease, making family support key in determining the course of disease, coping, and treatment. There was also considerable superstition over leprosy in the larger community often associated with sins in a past existence.^ieng

Tuberculosis prevention: where do we go from here?

PIP: The Karonga (Malawi) Prevention Trial revealed that repeat BCG vaccinations did not protect against pulmonary tuberculosis (TB) but appeared to provide some protection against glandular TB. They increased protection against leprosy. In fact, a single BCG vaccination conferred 50% protection against leprosy and a repeat BCG vaccination increased protection by another 50%. This trial's findings confirm the need for maintaining BCG vaccination programs in countries where leprosy is a public health problem, for individuals at high risk of leprosy (i.e., contacts of leprosy cases), and because BCG provides some protection against severe forms of TB (i.e., miliary disease and TB meningitis). An alternative TB vaccine needs to be developed, however. The protective efficacy of BCG against pulmonary TB is higher at latitudes far from the equator (80% in northern Europe vs. 0% in India and Malawi). It appears that the immunologic effects of environmental mycobacteria compromise BCG's protective effect against pulmonary TB. There is heterologous immunity between various mycobacterial infections. Low-level delayed-type hypersensitivity (DTH) to tuberculin in non-BCG vaccinated people reflects exposure to environmental mycobacteria. These people are at lower risk of TB than are people with either no DTH or strong DTH to tuberculin. Intradermal exposure to different mycobacteria provides varying degrees of protection against TB in guinea pigs. The warmer and the wetter the environment, the more widespread is colonization by mycobacteria. An area of future research is mapping the distribution of environmental mycobacteria, correlating it with the pattern of DTH responses to tuberculin, and then laboratory work to isolate relevant antigens of the mycobacteria. Another approach is identifying mycobacterial antigens that elicit protective immune responses in vitro so researchers can then identify which antigens and responses are associated with patterns of DTH known to reflect low risk of TB and which response patterns are elicited by BCG against leprosy but not TB antigens. New vaccines are not on the imminent horizon, however.^ieng

The population of persons with disabilities in Pakistan.

PIP: This article provides a discussion of deficiencies in the data collection on disabilities in Pakistan, identifies data sources, and makes recommendations for improving the quality of the data. Major trends in disabilities are identified. In Pakistan, there is social stigma attached to persons with disabilities. Disabilities are concealed within families so as not to limit the marriage prospects of relatives who might otherwise be suspected of carrying defective genes. Religion perpetuates superstitions about the disabled. Families bear an extra expense in caring for a disabled member, due to loss of additional labor, increased demands on resources for taking care of the disabled member, and increased need to compensate with higher fertility. There is a lack of social institutional support for care of the disabled. The population censuses of 1961 and 1981 were the first to collect information on the disabled. The inadequacy of census data led to the initiation of a national survey in 1984/85 for collecting data on blindness, deafness, mutism, leprosy, retardation, lameness, and handicaps. A special in-depth survey on disabilities was also conducted in Islamabad and Rawalpindi districts in 1986. This survey focused on mental retardation, visual and hearing disabilities, deformity and wasting of the limbs, and physical disabilities, such as paralysis. This survey was the most valid but it was not comparable to prior surveys. Trends indicate a smaller number of disabled at older ages. Specific disabilities by age showed some peculiar age patterns that suggest unreliability. Data from the 1984/85 survey show higher sex ratios for all disabilities for certain provinces compared to the national ratios. If the trend accurately reflects increased disabilities, the education of high risk groups must be improved, accessibility to medical care must be increased, and the population needs to be educated about the disabled. Government social programs need more accurate assessments of the causes of disability and the extent and duration of disablement.^ieng

Tuberculosis control programme in rural area: experiences from the field.

PIP: According to the Indian National Tuberculosis Program (NTP), only 30% of tuberculosis (TB) patients receiving conventional treatment and 52% of those receiving short-course chemotherapy (SCC) complete the treatment. Incompletely cured patients return to the community, and each sputum-positive case can infect 10-14 people in the course of a year. Direct monitoring of chemotherapy is a must for success, especially if rifampicin is used after accurate diagnosis based on bacteriological examination. The National Leprosy Eradication Program, which has involved voluntary organizations, provides an example to be followed by NTP. This example was considered when the Karuna Trust, a voluntary organization, launched a TB control program on January 1, 1992, for Yelandur taluk, covering a population of 69,484 in 40 villages. A staff consisting of a medical officer, a supervisor, a smear technician, and paramedical workers had undergone training at the National TB Institute in Bangalore. Detection of cases was carried out by house-to-house visits, which could detect about 65% of cases. It was also found that TB treatment had been started without a sputum examination, sputum-positive cases had been on rifampicin, and data recording was incomplete. Up to October 1994, a total of 231 cases were registered and compliance was ensured by home visits. Private practitioners were carrying out harmful activities by not enforcing full patient compliance and thereby contributing to the increasing number of drug-resistant cases. In contrast, this program had a default of only 19.1% among sputum-positive cases, but even these can be recovered with an interaction with private practitioners. Treatment failure amounted to 10.1%, all having been on rifampicin. Retreatment requires more expensive second-line drugs. Drug collection will be decentralized for the convenience of patients; and an adequate supply of drugs was secured. Some suggestions were also made concerning adequate resources, integration of the program, monitoring, and involving nongovernmental organizations in implementation and evaluation.^ieng

Leprosy care. The impact of multiple drug therapy.

PIP: There are currently an estimated 10-12 million cases of leprosy in the world. Until relatively recently, dapsone was the mainstay of drug therapy against this disease, but it had to be administered for very long periods of time and began to lose effectiveness in the face of growing disease resistance. New standard, multi-drug regimens were therefore recommended by WHO in 1982 and have since become the standard minimum necessary treatment in leprosy control programs. Multiple drug therapy (MDT), if administered early enough, can cure leprosy before deformity develops. Its cost and complexity, however, impede its widespread dissemination where needed. Much of rural Africa especially suffers from a lack of MDT due to financial constraints, geographic isolation, transport difficulties, and poor healthcare infrastructure. Dr, William Philip of the United Kingdom Aberdeen Royal Infirmary describes the introduction of MDT into and throughout rural northwestern Uganda over the period 1986-90. The introduction of MDT in West Nile has made a positive impact against leprosy. Most patients have been released from treatment or will be released soon after completing their regimes, so that only new cases will be receiving drug therapy. This large drop in case load will allow greater effort to be placed upon early case detection and treatment. MDT over time will reduce the number of patients needing drug therapy and leave only few disabled patients after a few decades. In so doing, MDT seems to be the approach needed to control and eventually eradicate leprosy. It is hoped that this program experience will help guide program implementation in other areas where MDT has yet to be introduced.^ieng

The social implications of population displacement and resettlement: an overview with a focus on the Arab Middle East.

PIP: Involuntary migration is broadly defined as displacement due to development projects, due to war or political upheaval or persecution, or due to natural disasters. The Middle East is considered as having its share of displacement. Migration of an involuntary nature is not covered very well in the literature. This article focuses on Sudanese or Nubian experiences, the Lebanese civil war, the Palestinian diaspora, and relief efforts. The literature review merges studies of refugee populations, victims of disasters, and relocation into a common theoretical orientation and examines the implications for displacement. Initial studies of population movements are identified as having a focus on the necessity and inevitability of dislocation resulting from development and modernization. Relief efforts receive more attention than group movements, and certain populations are at greater risk of migration. Migration is considered to be a demographic regulator as well as part of a natural process of adaptation. Movement within modernization theory is viewed as healthy and based on Western experiences. Case studies of displaced populations refute some of the assumed beneficial effects. Hansen and Oliver-Smith's articles reveal some of the problems with displacement theories. Attention is drawn to involuntary migration as a social event rather than a passive reaction to events, and several distinctions are made about types of migration and resettlement as a process. A new term for displacement from natural disasters is added (environmental refugees). A number of good case studies on involuntary migration are noted. The author posits that the relationship between push forces and strategies of adaptation should be analyzed as an interactive process that continuously informs decision making on national and local levels. Geographers are recognized by Oliver-Smith as among the first to clarify the role of development in creating environmental hazards. The analyses point to underdevelopment as a condition that forces the poor and most vulnerable to move into vulnerable and hazardous economic and geographic circumstances. The Middle East experience emphasize war refugees. The Nubian experience reflects the unnoticed impact of development and the role of the state. The crossover between labor migration and displacement and the pastoral economy is not adequately addressed.^ieng

Determinación de anticuerpos anti-glicolípido fenólico I en población general de un área endémica de lepra

Se estudiaron los niveles de anticuerpos anti-glicolípido fenólico I mediante ensayo inmunoenzimático por el Sistema Ultra Micro Analítico (SUMA), desarrolado en Cuba, en 26806 personas de la población general del municipio de Guantánamo, Cuba. En este municipio las tasas de prevalencia y de detección de casos de lepra fueron 5 y 4 veces mayores respectivamente que las del país en el año del estudio (1988). El 82'6 por ciento de los individuos mostraron valores por debajo del nivel de corte estabelecido, observándose entre los "seropositivos" una disminución de la frecuencia de acuerdo al aumento de la edad y una elevación en el sexo femenino. Se pudo precisar que 828 individuos "seropositivos" tenían contacto conocido con enfermos de lepra y que entre los que presentaron los valores más altos, la proporción de intradomiciliarios fue significativamente mayor que la de los extradomiciliares, lo que podría estar asociado con una exposición más intensa al M. leprae y con el reconocido mayor riego de enfermar que presentan los primeros. El examen de los "seropositivos" ha conducido, hasta el momento de la redación de este trabajo, al diagnóstico de 12 casos nuevos de lepra, de los cuales en 7 se comprobó la presencia de bacilos ácido-alcohol resistentes en la baciloscopía, por lo que constituían fuentes de infección en la comunidad.

Leprosy: an urgent need to step up use of MDT in Africa.

PIP: 10-12 million people in the world have leprosy. India claims about 4 million of these cases. Overall at least 20% of the cases are children. In the 1940s, dapsone was the only drug used to treat leprosy. By the early 1970s, dapsone did not perform as expected and Mycobacterium leprae were beginning to exhibit resistance to dapsone. In 1982, WHO published results of its study which recommended fixed and relatively short duration regimens of multiple drug therapy (MDT) for all people with leprosy. It also listed recommendations on diagnosis, classification, and distribution of patients to either pauci or multibacillary groups. MDT depends on what type of leprosy patients have. For example, patients with multibacillary leprosy receive rifampicin, clofazimine, and dapsone whereas those with paucibacillary leprosy receive only rifampicin. In many African countries, however, MDT is not used. Yet cases of leprosy exist in 94% of Africa's countries. Moreover 37% have highly prevalent leprosy and the lowest percentage of patients on MDT (18% vs. world average of 56%). In fact, Nigeria is included in the group of 5 countries with 84% of all cases. Until the various countries in Africa can satisfy the ideal requirements for establishing a MDT program, they should begin MDT at least on a small scale. They do need, however, an adequate supply of the drugs. The other requirements include a good plan of action, laboratory facilities, transport, and referral centers. If the period of time needed to meet these requirements is long, then physicians should conduct pre MDT screenings to diagnose cases and determine who needs chemotherapy. The best way to diagnose cases is from clinical experience and paying particular attention to dermatological and neurological findings. Early identification is needed since leprosy cases are stigmatized. This article includes MDT dosages in adults and children.^ieng

Care and development of children in tribal areas.

PIP: About 53 million people (8% of the population) of India belong to various tribes in about 400 tribal communities. These groups live in different ecological geoclimatic conditions throughout India ranging from the Sub-Himalayas to the islands in the Bay of Bengal and in the Arabian Sea. They also differ in distinct biological traits and cultural and socioeconomic background. Due to cultural patterns which vary from tribe to tribe, they are all at different stages of social, cultural, and economic development. Since the tribes live in isolated and inaccessible areas, it is hard to implement health care and nutrition activities, elementary education, and preventive promotive health care. The government does plan to provide rural day care for 0-3 year old children. The Integrated Child Development Services (ICDS) Scheme reaches 2197 of 5143 tribal development blocks. ICDS activities include immunization of children and mothers, health education, and supplementary nutrition. The government also promotes primary health care in tribal areas. Despite these efforts, child welfare and development in tribal areas have not improved. Recently nongovernmental organizations have joined child welfare and development efforts in tribal areas. The Jigyansu Tribal Research Center has compiled a long list of recommendations to improve child welfare and development efforts in tribal areas including improving preventive activities especially those that target specific local diseases such as cerebral malaria and leprosy, introduction of traditional herbal medicines, and comprehensive data collection.^ieng

Burma.

PIP: Demographic, political, and physical characteristics of Burma are outlined, the largest country on the Southeast Asian mainland. The population of Burma is predominantly rural with the most prevalent ethnic group being the Burmans. Theravada Buddhism is the religion of approximately 85% of the Burmese. Burma was unified in the 11th century by King Anawrahta. In 1988, General U Ne Win, the country's president, stepped down from his position after a series of violent riots protesting severe economic conditions. That same year, military rule was established and 2 new parties came into being: the National Unity Party and the National League for Democracy. Since August 1988, the issuance of tourist visas has been halted due to the unrest. Longterm visas for business purposes can be obtained, however. For those travelling to Burma, yellow fever inoculation certification is required. Cholera, tuberculosis, plague, leprosy and typhoid are all endemic as well, and dengue fever is present. A fairly inaccessible country, all international flights enter and exit through the country's capital, Rangoon. The tourist visiting Burma will see an agricultural nation. Approximately 70% of the country's exporting economy comes from the sale of rice and teak.^ieng

USAID in Nepal.

PIP: The USAID's mission in Nepal is to assist development until the people can sustain their own needs: although the US contributes only 5% of donor aid, USAID coordinates donor efforts. The mission's theme is to emphasize agricultural productivity, conserve natural resources, promote the private sector and expand access to health, education and family planning. Nepal, a mountainous country between India and Tibet, has 16 million people growing at 2.5% annually, and a life expectancy of only 51 years. Only 20% of the land is arable, the Kathmandu valley and the Terai strip bordering India. Some of the objectives include getting new seed varieties into cultivation, using manure and compost, and building access roads into the rural areas. Rice and wheat yields have tripled in the '80s relative to the yields achieved in 1970. Other ongoing projects include reforestation, irrigation and watershed management. Integrated health and family planning clinics have been established so that more than 50% of the population is no more than a half day's walk from a health post. The Nepal Fertility Study of 1976 found that only 2.3% of married women were using modern contraceptives. Now the Contraceptive Retail Sales Private Company Ltd., a social marketing company started with USAID help, reports that the contraceptive use rate is now 15%. Some of the other health targets are control of malaria, smallpox, tuberculosis, leprosy, acute respiratory infections, and malnutrition. A related goal is raising the literacy rate for women from the current 12% level. General education goals are primary education teacher training and adult literacy. A few descriptive details about living on the Nepal mission are appended.^ieng

Ophthalmic disease in Western Samoa.

Since the last report on eye disease in Western Samoa in 1959 by Dr. Elliott, the population has increased from 97,000 to 158,000. The country now has a full-time ophthalmologist but could benefit from a larger eye care service. The distribution of disease is very similar to that found in 1959, with pterygium, cataract and injuries comprising the most frequent eye problems. Acute angle-closure glaucoma is much more common than open-angle glaucoma and is associated with a plateau iris configuration.

Togo.

PIP: This compendium on Togo contains a summary of current and projected demographic indicators, of government population policies and attitudes, and of the current status of the country's population data collecting system. The information is further summarized in a 1-page fact sheet. In 1981 the total population was 2.7 million. In 1980-85, the annual population growth rate was 2.9%, and the annual natural increase rate was 2.9%, life expectancy at birth was 48.7 years, the infant mortality rate was 113, and the crude birth rate was 45.4. Per capita income was US$406 in 1979, and in 1981, 67% of the labor force was engaged in agriculture. Currently the government has no policies in regard to population growth and is satisfied with the current fertility level. Earlier the government's position was pronatalist; but, in 1976, the government approved the establishment of the Togolese Family Welfare Association (ATBEF), an affiliate of the International Planned Parenthood Federation. In addition, the government is promoting the integration of family planning services in the nation's primary health program. The government is concerned with the problem of teenage pregnancy. Abortion, except to save the life of the mother, is illegal, and there are no legal provisions concerning sterilization. In recent years, the government adopted several measures aimed at improving the status of women. These measures included the passage of a new family code. The major concerns of the government are to improve the health status of the population and to promote rural and regional development. The primary health care program was expanded in 1977, and the country has a fairly successful immunization program. It also operates a leprosy control program and is improving the country's water supply. Currently the level of international migration, both emigration and immigration, is low, and the government has no migration policy. Togo has a low urban rate (17.4%), and between 1970-80, the rate of annual urban growth rate was 5.3%. The government is concerned about the high rate of growth in Lome, the capital city. Togo conducts a census every 10 years, and the last one was conducted in 1981. Birth and death registration is incomplete. There is no institutionalized mechanism for promoting the integration of population and development planning.^ieng

[Essay on the history of population policy in Japan--around the concept of population quality].

PIP: The development of the concept of population quality is found in the history of population policy in prewar Japan. Between 1916 and 1926 the Japanese government was concerned with high death rate and low birth rate. The condition was attributed to the poor health condition of the population, and a committee was organized to investigate public health problems. The committee studied the following: 1) infants and children, 2) tuberculosis, 3) venereal disease, 4) leprosy, 5) psychoses, 6) food, clothing, and housing conditions, 7) rural area hygiene, and 8) vital statistics. The resulting population policy was illustrated by infant/toddler welfare and social welfare works. Between 1927 and 1930 the possibility of overpopulation was discussed in the background of depression. The government organized a committee of investigation pertaining to population and food problems in 1927. The interrelation of high birth rate and high death rate was noted in the report, and it was proposed that the country should maintain natural population increase by adopting a policy of low birth/death rates. The proposal favored the reasonable practice of birth control from the standpoints of public health and eugenics. Thus, the population quality concept was originated in the eugenic aspects of population policy when the nation was faced with the problem of population control in a quantitative sense.^ieng

Survival of mankind: the population viewpoint.

PIP: This article reviews the population sector of a conference on "The Survival of Humankind: The Philippine Experience," sponsored by the Philippine government and held September 5-10, 1977 at the Philippine International Convention Center. 178 scientists from 24 countries joined their Filipino counterparts to discuss 10 broad themes on human survival. The sector on population control and distribution had 2 subsectors: 1) contraceptive technology and its applications, and 2) population distribution and settlements. The 1st subsector head a paper by Dr. Allan Rosenfield, director of Columbia University's Center for Population and Family Health, on "The State of the Art in Contraceptive Technology and its Application." He suggested the use of paramedical personnel to deliver FP services, more community-based distribution of contraceptives, use of available resources in the Philippines for clinical testing and applied research, with basic studies left to already existing biomedical laboratory facilities. After comments by a panel of experts, the subsector issued a policy statement and recommendations incorporating these suggestions. The 2nd subsector heard a paper by Dr. Niles Hansen, chairman of the Human Settlements and Services Area, International Institute for Applied Systems Analysis, Austria, on "Population Distribution and Settlement in Developing Countries." He argued that the development of intermediate-size growth centers is economically the best strategy of human settlement. A panel of experts reacted to Dr. Hansen's presentation and suggestions and worked out a policy statement and recommendations urging consideration of the effect of other social and economic development programs on population distribution policies; stimulation of research on population movements; programs to help the migrant select and adjust to his new environment; attention to the problems of slums and squatter settlements; and better distribution of urban and regional population. Prerequisites to achieve these objectives are stronger land-use controls, better metropolitan governmental structures and integrated national, regional and local planning.^ieng