GEOG1- Health = AARON

Management of HIV/AIDS

1. Trying to find a vaccine- the hope of this seems remote, but research is continuing, particularly in trying to find groups that might possess some degree of natural immunity through their white cells. 2. Prolonging life through drugs- such drugs are available but expensive: a typical course of AZT cost US$10,000 a year per individual in 2000, but costs are now much lower at $300 for generic drugs such as Nevirapine. This is still beyond the reach of mots govts in less developed countries. In 2001, however, a court case against the South African govt by a group of multinational pharmaceutical companies was dropped because of massive public pressure on the companies. This means that the South African govt can now manufacture and import cheap generic versions of antiretroviral drugs instead of having to buy the expensive brand-name products. In 2003, South Africa announced that it would make available free HAART (Highly active antiretroviral therapy) treatment to everyone who was HIV-positive. In 2005, 17% of those needing HAART around the world were receiving it, funded by donations from Western countries. Some people argue that this is leading to complacency, as HAART is not a cure. 3. Plotting the course of an outbreak, making it possible to predict the future spread of the disease and identifying areas where resources should be concentrated. 4. Screening blood for HIV antibodies before it is used for transfusions in developed countries, leading to a negligible risk of infection. This was not always the case. Blood plasma products, such as fator eight (for haemophiliacs), are now treated to remove the virus. 5. Education and advertising- education is seen as the main way in which HIV/AIDS infection can be combated in sub-Saharan Africa. However, this assumes that humans are rational and their behaviour is under individual control. Often, due to social norms and prejudices, they are not. Education is aimed at increasing the use of condoms, but, in Africa in particular, they are not popular. In developed countries, education and advertising have been aimed at vulnerable groups such as homosexuals and intravenous drug users to try and prevent the spread of the disease. Raising the profile of the disease in schools through sex education has been a major feature in the UK government programme. Other campaigns in the UK have include free needles for drug users, free condoms, and warnings to travellers about their sexual behaviour in foreign countries. 6. Caring for victims and families, which involves charities such as the Terrence Higgins Trust and London Lighthouse in the UK. It is now believed that the spread of HIV/AIDS is rooted in problems of poverty, food and livelihood insecurity, sociocultural inequality, and poor support services and infrastructure. Although responses to HIV/AIDS have grown and improved over the past decade, they still do not match the scale or pace of a steadily worsening epidemic. Indeed, in a report published in 2005, UNAIDS said that 'the AIDS epidemic continues to outstrip global efforts to contain it'.

Implications for the provision of healthcare systems

Healthcare in the UK is provided within the context of the National Health Service (NHS).

Socialised healthcare

1. Healthcare is a state-provided public services. 2. Physicians are state-employed. 3. Professional associations are weak or non-existent. 4. Facilities are wholly publicly owned. 5. Payments for services are entirely indirect. 6. State's role in healthcare is total. EG/ China and Cuba.

National Health Service

1. Healthcare is a state-supported service. 2. Physicians operaye as solo entrepreneurs and as members of professional associations, which are strong. 3. Facilities are mainly publicly owned. 4. State's role in healthcare is central and direct. EG/ Canada or UK.

Pluralistic healthcare system

1. Healthcare is viewed as consumer product. 2. Physician operates as a solo entrepreneur. 3. Professional associations are powerful. 4. Private and public ownership of facilities. 5. State's role in healthcare is minimal and indirect. EG/ USA.

Emergent healthcare system

1. Healthcare viewed as an item of personal consumption. 2. Physician operates as a solo entrepreneur. 3. Professional associations are powerful. 4. Private ownership of facilities. 5. Direct payment to physicians. 6. State's role in healthcare is minimal 7. Development of local health workers. EG/ Sierra Leone, South Africa, Brazil, Kenya.

The significance of TNCs

1. TNCs control and coordinate economic activities in different countries and develop trade within and between units of the same corporation in different countries. 2. TNCs can exploit differences in the availability of capital, and costs of labour, land and building. 3. TNCs can locate to take advantage or govt policies in other countries, such as reduced tax levels, subsidies/grants or less strict environmental controls. They can get around trade barriers by locating production within the markets where they want to sell. 4. The large size and scale of operations of TNCs means they can achieve economies of scale, allowing them to reduce costs, finance new investment and compete in global markets. 5. Large companies have a wider choice when locating a new plant, although governments may try to influence decisions as part of regional policy or a desire to protect home markets. Governments are often keen to attract TNCs because inward investment creates jobs and boosts exports which assist the trade balance. TNCs have the power to trade off one country against another in order to achieve the best deal. 6. Within a country, TNCs have the financial resources to research several potential sites and take advantage of best communications, access to labour, cost of land and building, and government subsidies.

Issues related to famine relief

1. The cost of providing relief- all NGOs have overheads, the costs of which have to be met from the money raised through charitable donations. Donors to charities often question these internal costs, although they are generally very low. 2. Disaster fatigue- modern communication systems publicise disasters quickly but can lead to a feeling of helplessness in donors as yet another famine occurs. 3. The type of food provided- it must be available, non-perishable and easily transported. It must also be consumable, reflecting local tastes. Sending powdered milk to the drought-stricken area of Ethiopia in the mid-80s was a classic food-aid error because there was no clean water with which to make it up. 4. Infrastructure to deliver aid- there should be international- standard entry facilities into an area (a port or an airport) as well as adequate roads for delivery by lorry. 5. Coordination between aid agencies and national governments- this is essential when famine relief is necessary in an area of civil unrest. 6. Targeting aid- how can those most in need be identified? The long term response involves helping people to develop a more productive system of farming in order to prevent another famine. Such aid could involve: 1. Increased use of fertilisers and new technologies such as high-yielding varieties of seeds. 2. Improvements to systems to ensure that produce gets to markets more efficiently. 3. Easing international trade and cancelling national debts.

Insurance/ social security healthcare system

1.Healthcare is an insured and guaranteed consumer product. 2. Physician operates as a solo entrepreneur, and as members of professional associations, which are strong. 3. Private and public ownership of facilities. 4. Payment for services mostly indirect. 5. State's role in healthcare is evident but indirect. EG/ France, Japan and Spain.

A disease of affluence: CHD (coronary heart disease)

A heart attack occurs when the blood vessels supplying the heart muscle become blocked, starving it of oxygen and leading to the heart muscle's failure or death. A wide range of risk factors can be responsible for a heart attack, often acting in combination. The incidence of these factors varies around the world and so does the occurrence of the disease. The impact of the heart disease is measured both by deaths and by disability-adjusted life years (DALYs). DALYs are an indication of the number of healthy years of life lost. The measures indicate the total burden of disease, as opposed to just the number of deaths. Since 1990, more people around the world have died from coronary heart disease than from any other cause. Its disease burden is projected to rise from around 47 million DALYs globally in 1990 to 82 million DALYs in 2020. Variations in death rates are marked: they are lower in populations with short life expectancy. CHD is decreasing in many more developed countries due to improved prevention, diagnosis and treatment, and in particular reduced cigarette smoking and lower than average levels of blood pressure and cholestrol. However, it is increasing in less developed countries, partly as a result of increasing longevity, urbanisation and lifestyle changes. The WHO states that more than 60% of the global burden of coronary heart disease occurs in newly developing countries. Is this a disturbing sign of development?

Transnational corperations

A transnational corporation is a company that operates in at least two countries. It is common for TNCs to have a hierarchical structure, with head quarters and R&D department in the country of origin, and manufacturing plants overseas. As the organisation becomes more global , regional headquarters and R&D departments may develop in the manufacturing areas. TNCs take on many different forms and cover a wide range of companies involved in the following primary, secondary (manufacturing) and tertiary (service) activities: 1. Resource extraction, particularly in the mining sector, for materials such as oil and gas. 2. Manufacturing in three main sectors: (a) High tech industries such as pharmaceuticals (b) Large volume consumer goods such as motor vehicles (c) Mass produced consumer goods such as cigarettes, branded goods. 3. Services such as banking/finance, advertising, freight transport, hotels and fast-food operations. TNCs are the driving force behind economic globalisation. As the rules regulating the movement of goods and investment have been relaxed and the sources and destinations of investment have become more diverse, such companies have extended their reach. There are now few parts of the world where influence of TNCs is not felt and in many areas they are a powerful influence on the local economy. TNCs tend to be involved in a web of collaborative relationships with other companies across the globe.

Global patterns of health- definitions

Attack rate- the number of cases of a disease diagnosed in an area, divided by the total population, over the period of an epidemic. Case-mortality rate- the number of people dying from a disease divided by the number of those diagnosed as having the disease. Crude death rate- the number of deaths per 1,000 people in 1 year. Infant mortality- the number of deaths of children under the age of 1 year expressed per 1,000 live births per year. It is useful as a barometer of social and environmental conditions and is sensitive to changes in either. Morbidity- Illness and the reporting of disease. In the UK 2001 census respondents were asked how well they felt and whether they had a limiting long-term illness. Some diseases are so infectious that by law they must be reported; these are usually included in international surveillance programmes. Plague, cholera and yellow fever are the most serious, but malaria, influenza and typhoid are other examples. Mortality- the death of people. It is measured by a number of indices including death rate, infant mortality, case mortality and attack rate.

India

BAT has targeted the expanding market in India. According to the International Non-Governmental Coalition Against Tobacco (INGCAT): 1. Each day 55,000 children in India start using tobacco in some way. 2. About 5 million children in India under the age of 15 are already addicted to tobacco. 3. Although cigarettes form only about 20% of the Indian tobacco market, BAT is engaged in campaigns to convert 250 million tobacco users, particularly the young, to cigarette smoking. 4. The Indian government has relaxed investment rules so that TNCs can now have 100% ownership of their manufacturing plants (previously they had to be joint ventures).

Marketing and distribution

Branded drugs are unusual among consumer goods in the developed world in that their consumers tend to have little choice in the drug they purchase and use. Patients tend to use what their doctor prescribes for them. Therefore, the industry heavily targets doctors with its marketing, providing free samples of drugs, giving away everyday items (pens, calendars etc.), advertising in medical journals and arranging visits of sales representative to surgeries and offices. Another criticism aimed at pharmaceutical companies and WHO is that they tend to treat the symptoms rather than the root cause of the problem. For example, iron folate, a vitamin supplement, is on WHO's list of essential drugs. It is included because of its ability to prevent anaemia in pregnant women, a common problem in both the underdeveloped and developed world. However, a similar compound, with the same anaemia-preventing properties, is found in leafy green vegetables. It is possible that encouraging the growth of these vegetables would be more valid than promoting vitamin supplements.

Factors affecting regional variations- environment

Environment is also cited as a facto. The relationship between the wealther and various aspects of health has been studied in great detail. Relationships have been found between: 1. Temperature, heart disease and pneumonia, but these are more associated with seasonal variations of temperature than regional variations. 2. Rainfall and heart disease, which may impact on regional variations. Seasonality of mortality has declined in the UK since the 1960s, possibly due to the increased use of central heating. Air pollution was responsible for high morbidity and mortality from respiratory diseases before this period, and has declined. Other smaller-scale aspects of the environment have an influence on morbidity. The impact of background radiation may be a factor in some diseases. For example, some rocks in the south-west of England contain high amounts of radon, and the radioactivity from this is thought to be responsible for a higher risk of lung cancer in the area. Issues of water quality are significant. Hard water is found in the south and east, soft water in the north and west . A consistent relationship has been shown between soft water and high levels of heart disease. Deficiencies and excesses of certain trace elements in water a known to be harmful. Excesses of nickel, cadmium, mercury and lead are hazardous and high concentrations of aluminium in water have been suggested as an explanation for the geographic distribution of Alzheimer's disease.

Solutions to famine

Famine relief is a short-term aid that takes the form of distributing food. It is usually carried out by a combination of NGOs (like Oxfam and Red Cross) and government. Much of this aid is temporary in nature. It is usually given with caution because it could result in overdependence by the receiving country and might damage the local agricultural economy.

The NHS

HOW IT IS FUNDED: The NHS is a publicly funded healthcare system that is payed for by the government via taxes. The NHS accounts for around 16.5% of the UK government's total spending. HOW IT WORKS: People are able to choose a GP of their own liking and can swap and change GPs whenever they wish. Despite this, many GPs will only accept patients from a small catchment area, so in reality, there's a lot less choice in a person's GP. The GP acts as an access point to the NHS's specialist services. When a patient has a medical problem they can book an appointment with a GP who will then see the patient and attempt to diagnose them with a condition. Once the patient has been diagnosed, or if he/she can't be diagnosed, the patient is referred to a relevant department within a hospital or specialist treatment centre so that they can receive the care that they need. Obviously the GP method won't work during an emergency which is where the A&E (Accident & Emergency) department comes into play. All hospital's have an A&E department and it is a walk in department for people who have suddenly fallen critically ill. People can receive specialist treatment from an A&E department without a referral from their GP. WHO CAN ACCESS IT Anybody can access the NHS health service, even those who don't pay their national insurance tax such as immigrants. The only difficulty arrises when someone without an address tries to use the service. In order to obtain a GP, a person must have an address, so a homeless individual's medical care would be limited to the A&E section of hospital's only. The person would be unable to receive any follow up care after treatment in A&E due to their lack of a GP.

The USA healthcare

HOW ITS FUNDED: Healthcare in the USA is almost entirely private and is based on the free market and survival of the richest models. Individuals must choose a health insurance package that covers certain types of treatments and pay a monthly or yearly fee for that insurance. The cost of health insurance varies based on the package a person has. On average, healthcare for a family of four costs around $10,000 per year (about ½ the yearly wage of a Walmart employee). The health care services themselves receive little in terms of funding from the government, instead relying on payments from people for treatment. HOW IT WORKS Much like the French system, people can receive general treatments from a physician or receive specialist treatment at a hospital without the need for a referral. The treatment that a person can receive, however, is limited to the health insurance package that they are paying for. WHO CAN ACCESS IT As mentioned above, provided a person is paying enough for their insurance, they can access any health care services. If a person doesn't have the right insurance package for their treatment though, or if the person just doesn't have insurance, they must either pay the full price of the treatment upfront, beg for help from a charity or just do without the treatment. For people without insurance, a service called Medicaid provides very basic treatment from the state however it's very limited in terms of what treatment people can access. Medicare is a service that provides health insurance to those over the age of 65, again, paid for by the state.

Health in world affairs

Health geography can make an important contribution to future global and national plans and policies. This can include: 1. Advising on planning for healthcare staffing in southern African countries devastated by the HIV/AIDS crisis. 2. Analysing the global correlation between income and welfare. 3. Monitoring the effects of climate change on the emergence of new infectious diseases. 4. Investigating the optimum pattern of healthcare provision in primary healthcare trusts.

Factors affecting regional variations- health-related behaviours

Health-related behaviours may also affect geographic variations in health. Levels of education may also be a factor. Alcohol consumption and diet vary only a little between regions and therefore are likely to have limited influence on patterns of health. Attitudes to health, and in particular to exercise (again a reflection of education), may have an effect, but it is far from straightforward to quantify the effects.

Global patterns of morbidity- influenza

Influenza is caused by a virus that attacks the upper respiratory tract- the nose, throat and bronchi and sometimes also the lings. The infection usually lasts for about a week. It is characterised by sudden onset of high fever, headache and severe malaise, non-productive cough and sore throat. Most people recover within 1-2 weeks without requiring any medical treatment. In the very young, the elderly and people suffering from chronic medical conditions such as lung disease, diabetes, cancer, kidney or heart problems, influenza poses a serious risk. In these high-risk people, the infection may lead to severe complications, pneumonia and death Influenza spreads around the world in seasonal epidemics and imposes a considerable economic burden in the form of hospital and other healthcare costs and lost productivity. In annual influenza epidemics 5-15% of the population are affected with upper respiratory tract infections. Hospitalisation and deaths mainly occur in high risk groups. Although difficult to access, these annual epidemics are thought to result in between 3 and 5 million cases of severe illness and between 250,000 and 500,000 deaths every year around the world. Most deaths currently associated with influenza in industrialised countries occur among those over 65 years of ages. Much less is known about the impact of influenza in the developing world. However, influenza outbreaks in the tropics, where viral transmission normally continues year-round, tend to have high attack and case-mortality rates. For example, during an influenza outbreak in Madagascar in 2002, more than 27,000 cases were reported in 3 months and 800 deaths occurred despite rapid intervention. An investigation of the outbreak, coordinated by the World Health Organisation (WHO), found that there were severe health consequences in poorly nourished populations with limited access to adequate healthcare. Three times in the last century, influenza viruses have undergone major genetic changes resulting in global pandemics and large tolls in terms of both disease and deaths. The most infamous pandemic was 'Spanish Flu' which affected large parts of the world population and is thought to have killed at least 40 million people in 1918-19. Two other influenza pandemics occurred in 195 ('Asian influenza') and 1968 ('Hong Kong influenza') and caused significant morbidity and mortality globally. In contrast to current influenza epidemics, these pandemic had severe outcomes among healthy younger persons, although not on such a dramatic scale as the 'Spanish flu' where the death rate was highest among health young adults. Limited outbreaks of a new influenza subtype (H5N1) directly transmitted from birds to humans occurred in Hong Kong special administrative Region of China in 1997 and 2003 and there have been fears that this could cause a Pandemic.

Drought in Southern Ethiopia and Somalia, 2000.

Lack of rain which affected 43% of entire population. Had the following effects: 1. Led to unusual movements of people and live-stock as herders moved in search of water and fresh pasture. 2. As a result of these migrations, too much pressure was put on those areas that had sufficient water and pasture. 3. The lack of food and water took a heavy toll on herders and thousands of cattle, sheep, camels and goats died. 4. The death of livestock led to a deterioration in peoples nutritional status. 5. Milk, one of the main components of the diet (particularly that of women and children) became scarce. 6. Food prices began to rise. 7. Thousands of families abandoned their lands and headed for the cities. Many camps for these internally displaced persons had to be set up. One camp, on the outskirts of the town of Denan, contained at least 13,000 people. 8. Large amounts of foreign aid were required to run these camps; the rate of malnutrition was estimated at over 50%.

Regional variations in the UK- Life expectancy

Life expectancy in the UK is increasing. Across the country as a whole, men aged 65 can expect to live a further 16.6 years and women a further 19.4 years if mortality rates remain the same as they were in 2005. Women continue to live longer than men, but the gap is decreasing. In 1985, there was a difference of 4 years between male and female life expectancy at age 65 in the UK. By 2005 this had narrowed to 2.8 years. There are also more local variations. The southeast, southwest and east of England have the highest life expectancies. Scotland, the North East and the North West of England have the lowest.

Famine

Most famine results from a combination of natural events and human mismanagement. Some authorities refer to famine as a decline in the access to food, rather than to there not being enough food. Famines are not always widespread. They can be localised and can affect only one group or social class. In areas affected by famine, it is not uncommon to see food available in markets and some agricultural products being exported. The decline of food availability is said to be the result of deterioration in the entitlements of certain sectors of society. Poorer people have limited access to food as a consequence of weaker purchasing and bargaining powers. They have low status, menial occupations and limited land ownership. Famines on a large scale occur as a result of one or more of the following factors: 1. Drought- lack of rainfall causes soil and groundwater sources to decline, which ultimately leads to a reduction in the supply of water. The soil moisture will not meet the needs of particular plants and agricultural crops, creating serious problems for areas that depend on farming, both arable and pastoral. 2. A population increase greater than the rate of crop (food) production- this often occurs in areas where there is a sudden influx of refugees fleeing a war zone or an area of civil unrest. It can also occur as people migrate from one drought zone to another. 3. A rapid rise in the price of food stuffs and/or animals- this can occur when the quality of farmland and grazing land declines (often during a drought). It is further compounded by a breakdown in the local economy and marketing systems. Control mechanisms react too slowly and inflationary price rises fuel panic buying, which rapidly leads to shortages of basic foodstuffs.

Factors affecting regional variations- Socioeconomic

One explanation put forward for regional differences in health and morbidity is that they simply reflect a concentration of people of lower socioeconomic status. However, other factors also appear to influence patterns in the UK. Socioeconomic status does appear to be significant. 1. In all regions of England, babies born to fathers in social class 5 (unskilled and unemployed) have higher IMR rates than those born to fathers in social class 1 (professional and managerial). 2. Men aged 20-64 within social class 5 themselves have higher mortality than those in social class 1. 3. Furthermore, men in this class in the north of England have higher mortality and morbidity than those in the same class in the south of England. It is believed that the explanation for this lies in material deprivation particularly in terms of employment and housing. In addition, people in this social class display different behaviours towards health- more smoking less uptake of healthcare, lower ability to maintain health- and there is a cumulative effect of disproportionate numbers of disadvantaged people living in deprived areas. There is little geographic difference in mortality among those in social class 1.

Policies and legislation

Only govts can legislate for the prevention and/or control of disease. The most common legislation involves reducing tobacco smoking, which has clear links to reducing heart disease. Legislation can include advertising bans, smoke-free areas, health warnings on packets, taxation and outright bans in public places. A smoking ban was first introduced in Singapore in 1970 and 37 years later the idea was implemented in the UK. Another interesting form of legislation was introduced in the USA in 2004. The House of Representatives banned law suits against fast-food restaurants by obese customers who argue that they have become overweight by eating there.

Risk factors of CHD

Over 300 risk factors have been associated with CHD. Many of these are significant in all populations. In MEDCs, there are 5 major risk factors: 1. Tobacco use 2. Alcohol use 3. High blood pressure 4. High cholesterol 5. Obesity. In developing countries with low mortality, such as China, the same risk factors apply, with the additional risks of under nutrition and communicable diseases. In developing countries with high mortality, such as those of Sub-Saharan Africa, low vegetable and fruit intake are also important factors. Some major risks are modifiable in that they can be prevented, treated and controlled. There are considerable health benefits at all ages, for both men and women, in stopping smoking, reducing cholesterol levels and blood pressure, eating a healthy diet and increasing physical activity.

Obesity and overweight

Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health. BMI is a simple index of weight for height that is commonly used in classifying overweight and obesity in adult populations and individuals. It is define as the weight in kilograms divided by the square of the height in metres. The WHO defines 'overweight' as a BMI equal to or more than 25 and 'obesity' as a BMI equal to or more than 30. These cut-off points provide a benchmark for individual assessment, but there is evidence that the risk of chronic disease in some populations, such as people in Asia, increases progressively with a BMI of 22 and over. The new WHO Child Growth Standards, launched in April 2006, include BMI charts for infants and young children up to age 5. However, measuring overweight and obesity in children aged 5-14 years is challenging because a standard definition of childhood obesity is not applied worldwide. The WHO is currently developing an international growth reference for school-age children and adolescents WHO's global figures indicate that in 2005: 1. Approximately 1.6 billion adults were overweight. 2. At least 400 million adults were obese. 3. At least 20 million children under the age of 5 years were overweight. Childhood obesity is a big problem in the USA where over 35% of children are overweight. WHO further projects that, by 2015, approximately 2.3 billion adults will be overweight and more than 700 million will be obese. Overweight and obesity were once considered to be problems of high-income countries, but are dramatically on the rise in low and middle income countries, particularly in urban areas.

Health consequences of obesity and being overweight

Overweight and obesity can have serious health consequences. Risk increases progressively as BMI increases.Raised BMI is a major factor for chronic disease such as: 1. Cardiovascular disease (mainly heart disease and strokes)- already, the worlds number one cause of death, killing 17 million people each year. 2. Diabetes, which has rapidly become a global epidemic. WHO projects that diabetes deaths will increase by more than 50% worldwide in the next 10 years. 3. Musculoskeletal disorders, especially osteoarthritis. 4. Some cancers (endometrial, breast and colon). Childhood obesity is also associated with a higher chance of premature death and disability in adulthood. Life expectancy is reduced by an average of 14 years for obese smokers compared with non-smokers of normal weight. More than 60% of adults in the USA are overweight or obese. Triple-width coffins, capable of holding a 300kg body, are in increasing demand. There are 70 million overweight people in China and the South Pacific now has some of the worlds highest rates of obesity. Many low and middle income countries are now facing a 'double burden' of disease. While they continue to deal with the problems of infectious disease and undernutrition, they are at the same time experiencing a rapid upsurge in chronic disease risk factors such as obesity and overweight, particularly in urban settings. It is not uncommon to find undernutrition and obesity existing side by side in the same country, the same community and even the same household. This double burden is caused by inadequate prenatal, infant and childhood nutrition followed by lack of physical activity and exposure to high-fat, energy-dense, micronutrient-poor foods.

Reducing overweight and obesity

Overweight and obesity, as well as their related chronic diseases, are largely preventable. At an individual level, people can: 1. Achieve a healthy weight by reducing calorie intake and exercising more. 2. Limit energy intake from fats and shift fat consumption from saturated to unsaturated fats. 3. Increase consumption of fruit and vegetables, as well as legumes, whole grains and nuts. 4. Limit the intake of sugars. 5. Increase physical activity- at least 30 mins of regular, moderate-intensity activity on most days. Most activity may be required for weightloss. The implementation of these recommendations requires sustained political commitment. Governments, NGOs and the private sector have vital roles to play in shaping healthy environments and making healthier diet options affordable and accessible. This is especially important for the most vulnerable in society- poor people and children- who have limited choices about the food they eat and the environments in which they live. The following initiatives by the food industry could accelerate health gains worldwide: 1. Reducing the fat, sugar and salt content of processed foods. 2. Reducing portion sizes. 3. Introducing innovative, healthy and nutritious choices. 4. Reviewing current marketing practices.

Branded pharmaceuticals

Pharmaceuticals can be sold under two broad categories: generic or branded. Branded medicines, as with branded clothes, are more expensive than their generic counterparts. However, the generic name of a drug is its chemical description. This means that generic drugs are chemically identical to their brand-named equivalents. The generic name for a drug tends to be long and hard to remember whereas the brand name is often catchy. For example, the generic drug fluoxetine hydrochloride is marketed successfully as Prozac by its manufacturer Eli Lilly. The same drug is also marketed by other companies under the names of Erocarp, Lovan and Zactin. Branded drugs may be three to thirty times more expensive to purchase, making them prohibitive for much of the world's population. For any brand-name drug to be more well-known and popular than the generic equivalent, marketing forces must be involved.

Tobacco transnationals

Philip Morris, R.J. Reynolds and British American Tobacco (BAT), the world's largest non-state owned tobacco producing TNCs, own or lease plants in more than 60 countries. These three companies have a total revenue of more than US$70 billion, a sum greater than the combined GDP of Costa Rica, Lithuania, Senegal, Sri Lanka, Uganda and Zimbabwe. Of the 1.2 billion smokers in the world, 800 million are in the developing world. Countries where consumption is growing the fastest are also among the world's poorest, and it is these countries that the major tobacco TNCs are targeting with their advertising and marketing campaigns. China's increase in tobacco consumption has been the most dramatic. Nearly 70% of Chinese men smoke, compared with just 4% of Chinese women. This means that China alone accounts for 300 million smokers, almost the same number as in all the developed world.

Prevention strategies of CHD

Significant health gains in the treatment of heart disease can be made within a short period of time through public health and treatment intervention. Governments are stewards of health resources and have a fundamental responsibility to protect the health of citizens. They can do this by educating the public, making treatments affordable and available and advising patients on healthy-living practices. Some examples of prevention strategies are: 1. In the UK, dieticians promote the benefits for heart health of eating oily fish, more fruit and vegetables, and less saturated fat. 2. In Finland, community-based interventions, including health educations and nutrition labelling, have led to population-wide reductions in cholesterol levels closely followed by a sharp decline in heart disease. 3. In Japan, govt-led health education campaigns and increased treatment of high blood pressure have reduced blood-pressure levels in the population. 4. In New Zealand, the introduction of recognisable logos for healthy foods has led many companies to reformulate their products. The benefits include greatly reduced salt content in processed foods. 5. In Mauritius, a change from palm oil to soya oil for cooking has brought down cholesterol levels, but obesity has been unaffected.

Global patterns of mortality

Some of the highest crude death rates are found in the less developed countries, particularly in sub-Saharan Africa. Liberia, Niger, Sierra Leone, Zambia and Zimbabwe all have death rates of 20 or more per 1,000. However, some of the lowest mortality rates are also found in countries at the lower end of the development range, for example Kuwait (2 per 1,000), Bahrain (3 per 1,000) and Mexico (5 per 1,000). Infant mortality is falling across the world, but there are still wide variations between nations- 142 infant deaths per 1,000 births in Liberia, compared to 3 per 1,000 in Finland. Areas with high rates of infant mortality have high rates of mortality overall. HIV/AIDS is having a major impact on mortality around the world but especially in sub-Saharan Africa. More than 40 million people are now living with HIV/AIDS, over 25 million of them in sub-Saharan Africa. In Swaziland, Botswana, Lesotho and Zimbabwe, over 20% of the total population of the country are affected. Asia is also badly affected and of the 7 million HIV/AIDS victims in south/southeast Asia, over 5 million live in India. It is estimated, however, that infection rates have begun to decline in a number of countries.

AIDS in Sub-Saharan Africa: Botswana

The AIDS pandemic has had a huge impact on Botswana. The country has a total population of 1.6 million and it has been estimated that 24% of adults are infected with HIV. In the northeast of the country and among expectant mothers in urban areas, rates are over 50%. The govt has tried to manage the spread of the disease by focusing on prevention, but in 2002 Botswana became the first African country to provide free antiretroviral drugs. It is able to do this because it has the most lucrative diamond mines in the world and, as a result, per capita income is seven times the average for sub-Saharan Africa. Life expectancy in the country has dipped to below 40 years of age for the first time since 1950 and in 2006 stood at just under 34 years. It would have been expected to rise to 74 years and 5 months by 2010 if there had been no AIDS pandemic, but the current projected figure for that year is only 26 years and 8 months. The economy of the country has been affected because AIDS is destroying the workforce. It is predicted that the economy of the country will be one-third smaller by 2021 than it would have been without AIDS, while govt expenditure will have to increase by 20%.

Food and health

The Food and Agricultural Organisation (FAO) of the UN insists that there is sufficient food for everyone in the world. Food is not in short supply- globally, we produce enough to fee everyone with 2,700 calories per day. However, an estimated 30 million people die every year from starvation and a further 800 million suffer from chronic malnutrition. Some of these people live in countries that export food products to the developed world. Malnutrition is defined as a condition resulting from some form of dietary deficiency. This may be because the quantity of food, measured in calories per day, is too low or because certain important nutrients are absent. Malnutrition weakens immunity and makes people more vulnerable to diseases. It may also lead to deficiency disease such as Beriberi or anaemia. Some authorities refer to the condition that results from consuming too little food over a period of time as undernourished.

Healthcare in Wirral

The Wirral Primary Care Trust (WPCT) decides on health services needed by the population and secures the continual provision of the services that are needed for the general population. The Wirral Hospitals Trust is responsible for most major operations and specialist treatments. The WPCT provides primary care and services itself and commissions other organisations to provide secondary care. The primary care provided includes doctors, dentists, opticians, pharmacists & health visitors. The WPCT provides over 60 GP surgeries. the only way to gain access to a WHT department is via a referral from a GP or directly through A&E. The Cheshire & Wirral Partnership NHS Trust provides specialist treatment and services for people with mental health issues, learning disabilities and drug & alcohol problems. Clatterbridge Centre for Oncology is an NHS foundation trust. It provides specialist cancer treatment for most of the north west of England.

Healthcare in Wirral- location

The Wirral is located in the north west of England. It's a peninsula and is separated from the city of Liverpool by the River Mersey and from Wales by the River Dee (or, more specifically, their estuaries). To the north of the Wirral is the Irish Sea. The Wirral itself has several large(ish) towns including Caldy, Hoylake & West Kirby in the west and Wallasey & Birkenhead in the north and east respectively.

Health education

The above strategies are not effective without public understanding, support and demand. Health education is essential to promote healthy choices. Schools are an ideal venue for health education as they can provide a healthy diet, prohibit smoking and allow opportunities for exercise. WHO has initiated a number of activities to assist schools around the world, and since 2000 has coordinated World Heart Day events and activities including: 1. Medical activities such as blood pressure testing. 2. Activities to engage the public in physical activity. 3. Scientific conferences. 4. Activities to promote a heart-healthy diet. The number of countries taking part in World Heart Day increased from 63 in 2000 to 120 in 2006.

Economic costs of CHD

The economic costs of heart disease include the cost to the individual and to the family of healthcare and time off work, the cost to the government of healthcare and the cost to the country of lost productivity. All of these are difficult to quantify. Some statements about costs are: 1. If only 10% of adults began walking regularly, Americans could save US$5.6 billion in costs related to heart disease'. 2. The direct costs of physcial inactivity accounted for an estimated $24 billion in healthcare costs in 1996 (WTO). 3. Healthcare costs associated with smoking-related illnesses result in a global net loss of $200 billion per year, with one-third of those losses occurring in developing countries (WTO). 4. Cholesterol-reducers were the top-selling medications in 2003, generating $14 billion in sales (WTO). 5. The direct cost of obesity to the NHS is £0.5 billion per year, while the indirect cost to the UK economy is at least £2 billion according to the UK Chief Medical Officer in 2003.

Causes of obesity and overweight

The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended. Global increases in overweight and obesity can be attributed to a number of of factors, including: 1. A global shift in diet towards increased intake of energy-dense foods that are high in fat and sugars but low in vitamins and minerals. 2. A trend towards decreased physical activity due to the increasingly sedentary nature of many forms of work, changing modes of transportation and increasing urbanisation.

The Wirral Health Profile

The health of people in the Wirral varies greatly both within the area and when compared to the rest of England. Many health statistics are worse than their average throughout England. For example, Wirral's average life expectancy for men & women is lower than the national average. In addition, the number of people who eat 'healthy food' in the Wirral is less than the national average. Conversely, The number of adults who smoke cigarettes, for example, is less than the national average. In addition, the number of people who are obese is also lower than the national average. There are inequalities in the Wirral in terms of employment, environmental and deprivation and these inequalities many statistics are also better than the national average's. have different effects on the health of people in different areas of the Wirral. People in the north & east of the Wirral, for example, generally have lower health standards due to a more deprived lifestyle. Conversely, people in the west of the Wirral in areas such as Caldy & Hoylake, have better healthcare and longer life expectancies due to a higher standard of living and a (generally) higher income. The Wirral Strategic Partnership has prioritised health inequalities including smoking, alcohol abuse, employment, teenage pregnancies and child obesity.

Drug development

The largest profits in the pharmaceutical industry come from the sale of brand-name drugs in developed countries. Research into tropical diseases affecting hundreds of millions of people in less developed countries receives only a small proportion of the sum spent on cancer research. Most money is spent on developing drugs to control 'diseases of affluence' such as heart disease, cancer and high blood pressure. Patents for new drugs are viewed as 'intellectual property' and it is illegal to make generic 'copies' of them for 20 years. Therefore, many new drugs that WHO may regard as essential are not available in generic form. Pharmaceutical companies are criticised for this but point out the enormous investment into research and development required to develop a new drug. The money to fund this research comes partly from their profits.

Pharmaceutical transnationals

The modern pharmaceutical industry is a lucrative one. The geographical distribution of the largest ten pharmaceutical companies in the world is interesting. Five have headquarters in the USA, two in Switzerland, one in France and two in the UK. They are all successful examples of globalisation. For example Johnson & Johnson has more than 190 operating companies in 52 countries, selling products to 175 countries.

What is the role of other providers

The role of private healthcare has increased in recent years. Private health organisations such as BUPA offer a quick and efficient service to people who can pay insurance premiums, which are often met by their employers. Private companies tend to offer a more speedy response to elective surgery whereas acute situations are still dealt with by the NHS. Charitable organisations offer wider support than the NHS. They tend to concentrate on welfare as much as on health. Examples include: 1. the Down Syndrome Educational Trust 2. Macmillan Cancer Support 3. the hospice movement 4. organisations such as Shelter and Help the Aged. People who work for these organisations are a necessary part of the total provision of health and welfare in the UK. Many of them are unpaid volunteers.

Health priorities/services in Wirral

The services provided to combat these health inequalities include: 1.Free health clinics. 2. Free activities e.g. Yoga, Salsa dancing, 5-a-side football etc. 3. Free healthy living courses e.g. Healthy cookery lessons, Stop smoking courses etc. 4. Extensive opportunities for leisure through parks, open spaces and the coastline.

Production in developing countries

Tobacco TNCs are turning to developing countries not only to expand their markets but also as a source of cheaper tobacco. The danger with this is that tobacco cultivation will replace food crops. In Kenya, food production in tobacco-growing districts has decreased as farmers have shifted from food crops to tobacco. BAT is the largest agribusiness company in Kenya, contracting over 17,000 farmers to cultivate tobacco in an area of around 15,000 hectares. The situation is similar in Brazil, the world's largest exporter of tobacco. Brazilian tobacco is primarily used by Philip Morris to make less expensive brands. Cigarettes made with tobacco grown in the USA cost twice as much. Like many other international companies, tobacco TNCs are shifting production overseas to take advantage of cheaper labour costs. They have all started production in Asian countries. For example, R.J. Reynolds has a factory in Vietnam which is used to supply German and Canadian markets. Damon, one of the world's largest tobacco- leaf dealers, also has an office in Vietnam, where is is developing new crop varieties for what it hopes to be a growing market. Vietnam sells most of its tobacco for less than US$3 per KG.

Essential drugs

WHO regularly publishes updated lists of 'essential drugs'. These are generic drugs that can provide safe, effective treatment for most communicable and non-communicable disease such as diarrhoea, tuberculosis and malaria. These lists are widely regarded as an important tool in increasing access for the worlds populations to effective healthcare. They are however, unpopular in countries with strong pharmaceutical industries. The WHO essential drug list is not implemented in the USA or any EU country. This is because of business goals (i.e. profit) of manufacturers. In the USA, the federal government is now prevented from encouraging the use of generic drugs following legal action from the Pharmaceutical Manufacturers Association.

Morbidity

at a country level: 1. Scotland has the highest rates of lung cancer, heart diseases, strokes and alcohol and drug-related problems. 2. Wales has the highest incidence of breast, prostate and bowel cancer. 3. Northern Ireland has the highest rate of respiratory diseases. 4. England has the lowest rates for most of these. At regional level within England, a north-south divide in health is evident in some cases but not in others. Regions in the north have a higher mortality from heart disease, strokes and lung cancer. London has the highest rates for infectious and respiratory diseases. Alcohol related problems to not show a regional pattern. There is little variation in the incidence of bowel cancer, whereas breast and prostate cancer rates are higher in the south than in the north. Age appears to be a factor for some aspects of morbidity. For example, in London heart disease incidence at ages 45-64 is below average, whereas the incidence of strokes for this age group is high. Urban areas tend to have higher levels of morbidity. Deprivation is often given as the main reason for this, but many areas of deprivation exist in rural parts.