Showing papers in "Bulletin of The World Health Organization in 2001"

Corneal blindness: a global perspective

Abstract: Diseases affecting the cornea are a major cause of blindness worldwide, second only to cataract in overall importance. The epidemiology of corneal blindness is complicated and encompasses a wide variety of infectious and inflammatory eye diseses that cause corneal scarring, which ultimately leads to functional blindness. In addition, the prevalence of corneal disease varies from country to country and even from one population to another. While cataract is responsible for nearly 20 million of the 45 million blind people in the world, the next major cause is trachoma which blinds 4.9 million individuals, mainly as a result of corneal scarring and vascularization. Ocular trauma and corneal ulceration are significant causes of corneal blindness that are often underreported but may be responsible for 1.5-2.0 million new cases of monocular blindness every year. Causes of childhood blindness (about 1.5 million worldwide with 5 million visually disabled) include xerophthalmia (350,000 cases annually), ophthalmia neonatorum, and less frequently seen ocular diseases such as herpes simplex virus infections and vernal keratoconjunctivitis. Even though the control of onchocerciasis and leprosy are public health success stories, these diseases are still significant causes of blindness--affecting a quarter of a million individuals each. Traditional eye medicines have also been implicated as a major risk factor in the current epidemic of corneal ulceration in developing countries. Because of the difficulty of treating corneal blindness once it has occurred, public health prevention programmes are the most cost-effective means of decreasing the global burden of corneal blindness.

The burden of disease and injury in Australia

Abstract: An overview of the results of the Australian Burden of Disease (ABD) study is presented. The ABD study was the first to use methodology developed for the Global Burden of Disease study to measure the burden of disease and injury in a developed country. In 1996, mental disorders were the main causes of disability burden, responsible for nearly 30% of total years of life lost to disability (YLD), with depression accounting for 8% of the total YLD. Ischaemic heart disease and stroke were the main contributors to the disease burden disability-adjusted life years (DALYs), together causing nearly 18% of the total disease burden. Risk factors such as smoking, alcohol consumption, physical inactivity, hypertension, high blood cholesterol, obesity and inadequate fruit and vegetable consumption were responsible for much of the overall disease burden in Australia. The lessons learnt from the ABD study are discussed, together with methodological issues that require further attention.

Inherited haemoglobin disorders: an increasing global health problem.

Abstract: Despite major advances in our understanding of the molecular pathology, pathophysiology, and control and management of the inherited disorders of haemoglobin, thousands of infants and children with these diseases are dying through lack of appropriate medical care. This problem will undoubtedly increase over the next 20 years because, as the result of a reduction in childhood mortality due to infection and malnutrition, more babies with haemoglobin disorders will survive to present for treatment. Although WHO and various voluntary agencies have tried to disseminate information about these diseases, they are rarely mentioned as being sufficiently important to be included in setting health care priorities for the future. It takes considerable time to establish expertise in developing programmes for the control and management of these conditions, and the lessons learned in developed countries will need to be transmitted to those countries in which they occur at a high frequency.

Childhood blindness in the context of VISION 2020: the right to sight

Abstract: The major causes of blindness in children vary widely from region to region, being largely determined by socioeconomic development, and the availability of primary health care and eye care services. In high-income countries, lesions of the optic nerve and higher visual pathways predominate as the cause of blindness, while corneal scarring from measles, vitamin A deficiency, the use of harmful traditional eye remedies, and ophthalmia neonatorum are the major causes in low-income countries. Retinopathy of prematurity is an important cause in middle-income countries. Other significant causes in all countries are cataract, congenital abnormalities, and hereditary retinal dystrophies. It is estimated that, in almost half of the children who are blind today, the underlying cause could have been prevented, or the eye condition treated to preserve vision or restore sight. The control of blindness in children is a priority within the World Health Organization's VISION 2020 programme. Strategies need to be region specific, based on activities to prevent blindness in the community--through measles immunization, health education, and control of vitamin A deficiency--and the provision of tertiary-level eye care facilities for conditions that require specialist management.

The Epidemiologic Transition: A Theory of the Epidemiology of Population Change

Abstract: Although d emography c ontinues t o b e t he most prominent discipline concerned with population dynamics, involvement of other disciplines is highly desirable The case for a multidisciplinary approach to population theory has been aptly stated by Kurt Mayer: “Any meaningful interpretation of the cause and effects of population changes must extend beyond formal statistical measurement of the components of change, ie fertility, mortality and migration, and draw on the theoretical framework of several other disciplines for assistance (Mayer 1962)” In noting that the “analysis of the causal determinants and consequences of population change forms the subject matter of population theory,” Mayer inferentially acknowledges the epidemiologic character of population phenomena, for as its etymology indicates, (epi, upon; demos, people; logos, study), epidemiology is the study of what “comes upon” groups of people More specifically, epidemiology is concerned with the distribution of disease and death, and with their determinants and consequences in population groups Inasmuch as patterns of health and disease are integral components of population change, epidemiology’s reservoir of knowledge about these patterns and their determinants in population groups serves not only as a basis for prediction of population change but also as a source of hypotheses that can be further tested to correct, refine and build population theory Furthermore, many epidemiologic techniques that have heretofore been limited to the examination of health and disease patterns can be profitably applied as well to the exploration of other mass phenomena, such as fertility control

Sick individuals and sick populations

Abstract: Aetiology confronts two distinct issues: the determinants of individual cases, and the determinants of incidence rate. If exposure to a necessary agent is homogeneous within a population, then case/ control and cohort methods will fail to detect it: they will only identify markers of susceptibility. The corresponding strategies in control are the 'high-risk' approach, which seeks to protect susceptible individuals, and the population approach, wich seeks to control the causes of incidence. The two approaches are not usually in competition, but the prior concern should always be to discover and conttrol the causes of incidence.

Effective screening programmes for cervical cancer in low- and middle-income developing countries

Abstract: Le cancer du col constitue un important probleme de sante publique chez les femmes adultes des pays en developpement d'Amerique du Sud, d'Amerique centrale, d'Afrique subsaharienne, d'Asie du Sud et d'Asie du Sud-Est. Dans les pays developpes, des programmes repetes de depistage cytologique, soit organises soit ponctuels, ont conduit a une baisse importante de l'incidence du cancer du col et de la mortalite qui lui est associee. En revanche, le cancer du col reste une affection le plus souvent non maitrisee dans les pays en developpement a haut risque en raison de l'absence ou de l'inefficacite du depistage. Le present article passe brievement en revue les initiatives actuelles en matiere de depistage et de recherche dans ces pays. Le cout de l'infrastructure, du personnel, des produits renouvelables, du suivi et de la surveillance est eleve, qu'il s'agisse de programmes de depistage organises ou ponctuels. Les ressources qu'ils peuvent consacrer aux soins de sante etant limitees, les pays en developpement ne peuvent adopter les programmes en usage dans les pays developpes, qui comportent des depistages frequemment repetes sur une tranche d'âge plus etendue. Les services de sante de nombreux pays en developpement a faible revenu, dont la plupart en Afrique subsaharienne, n'ont ni les ressources ni la capacite d'organiser et de poursuivre des programmes de depistage quels qu'ils soient. Les pays en developpement a revenu moyen, dans lesquels le depistage est actuellement inefficace, devront reorganiser leurs programmes a la lumiere de l'experience des autres pays et des lecons de leurs echecs passes. Ceux de ces pays qui envisagent d'organiser un nouveau programme de depistage devront commencer par une region geographique limitee avant de songer a une quelconque extension. Il est egalement plus realiste et plus efficace d'axer le depistage sur les femmes a haut risque, qui seront soumises une fois ou deux dans leur vie a un test tres sensible, en cherchant a obtenir une couverture elevee (>80 %) de la population visee. Pour organiser un programme de depistage efficace dans ces pays, il faudra trouver des ressources financieres suffisantes, developper les infrastructures, former le personnel necessaire et elaborer des mecanismes de surveillance pour depister, examiner, traiter et suivre les femmes appartenant au groupe cible. On tiendra compte des resultats des nombreuses recherches portant sur les diverses approches du depistage dans les pays en developpement ainsi que des directives de gestion existantes lorsqu'on reorganisera des programmes en cours ou que l'on envisagera de nouvelles initiatives en matiere de depistage.

Safe management of wastes from health care activities

Abstract: Safe management of wastes from health-care activities , Safe management of wastes from health-care activities , کتابخانه دیجیتال جندی شاپور اهواز

The global tuberculosis situation and the new control strategy of the World Health Organization

Abstract: In 1989/90 the WHO Tuberculosis Unit undertook a special study to determine the nature and magnitude of the global tuberculosis problem by reviewing the official statistics and the available data from both published and unpublished field studies. The findings revealed that about 1700 million people or one-third of the worlds population are or have been infected with Mycobacterium tuberculosis with 8 million new cases found in developing and industrialized countries. It estimated that the disease caused 2.9 million deaths in 1990 making this the largest cause of death from a single pathogen in the world. While the largest number of deaths occurred in the Southeast Asian Region (940000) the Western Pacific Region (890000) and the African Region (660000) it is estimated that more than 40000 deaths still occur annually in the industrialized nations. Given the existing tuberculosis situation in the world the WHO has developed a new tuberculosis control strategy the development of which was based on a series of workshops and case studies in the last 2 years. These strategies include: 1) the introduction of short-course chemotherapy in place of the standard chemotherapy to improve the cure rate; and 2) the expansion of tuberculosis services.

Cataract blindness: challenges for the 21st century

Abstract: Cataract prevalence increases with age. As the world's population ages, cataract-induced visual dysfunction and blindness is on the increase. This is a significant global problem. The challenges are to prevent or delay cataract formation, and treat that which does occur. Genetic and environmental factors contribute to cataract formation. However, reducing ocular exposure to UV-B radiation and stopping smoking are the only interventions that can reduce factors that affect the risk of cataract. The cure for cataract is surgery, but this is not equally available to all, and the surgery which is available does not produce equal outcomes. Readily available surgical services capable of delivering good vision rehabilitation must be acceptable and accessible to all in need, no matter what their circumstances. To establish and sustain these services requires comprehensive strategies that go beyond a narrow focus on surgical technique. There must be changes in government priorities, population education, and an integrated approach to surgical and management training. This approach must include supply of start-up capital equipment, establishment of surgical audit, resupply of consumables, and cost-recovery mechanisms. Considerable innovation is required. Nowhere is this more evident than in the pursuit of secure funding for ongoing services.

Client satisfaction and quality of health care in rural Bangladesh

Abstract: OBJECTIVE: To assess user expectations and degree of client satisfaction and quality of health care provided in rural Bangladesh. METHODS: A total of 1913 persons chosen by systematic random sampling were successfully interviewed immediately after having received care in government health facilities. FINDINGS: The most powerful predictor for client satisfaction with the government services was provider behaviour, especially respect and politeness. For patients this aspect was much more important than the technical competence of the provider. Furthermore, a reduction in waiting time (on average to 30 min) was more important to clients than a prolongation of the quite short (from a medical standpoint) consultation time (on average 2 min, 22 sec), with 75% of clients being satisfied. Waiting time, which was about double at outreach services than that at fixed services, was the only element with which users of outreach services were dissatisfied. CONCLUSIONS: This study underscores that client satisfaction is determined by the cultural background of the people. It shows the dilemma that, though optimally care should be capable of meeting both medical and psychosocial needs, in reality care that meets all medical needs may fail to meet the client’s emotional or social needs. Conversely, care that meets psychosocial needs may leave the clients medically at risk. It seems important that developing countries promoting client-oriented health services should carry out more in-depth research on the determinants of client satisfaction in the respective culture.

Bulletin of the World Health Organization

Abstract: OBJECTIVE: To examine whether a family history of high-risk groups for major noncommunicable diseases (NCDs) was a significant risk factor for these conditions among family members in a study population in the Gambia, where strong community and family coherence are important determinants that have to be taken into consideration in promoting lifestyle changes. METHODS: We questioned 5389 adults as to any first-degree family history of major noncommunicable diseases (hypertension, obesity, diabetes and stroke), and measured their blood pressure (BP) and body mass index (BMI). Total blood cholesterol, triglyceride, uric acid, and creatinine concentrations were measured in a stratified subsample, as well as blood glucose (2 hours after ingesting 75 g glucose) in persons aged 35 years. FINDINGS: A significant number of subjects reported a family history of hypertension (8.0%), obesity (5.4%), diabetes (3.3%) and stroke (1.4%), with 14.6% of participants reporting any of these NCDs. Subjects with a family history of hypertension had a higher diastolic BP and BMI, higher cholesterol and uric acid concentrations, and an increased risk of obesity. Those with a family history of obesity had a higher BMI and were at increased risk of obesity. Individuals with a family history of diabetes had a higher BMI and higher concentrations of glucose, cholesterol, triglycerides and uric acid, and their risk of obesity and diabetes was increased. Subjects with a family history of stroke had a higher BMI, as well as higher cholesterol, triglyceride and uric acid concentrations. CONCLUSION: A family history of hypertension, obesity, diabetes, or stroke was a significant risk factor for obesity and hyperlipidaemia. With increase of age, more pathological manifestations can develop in this high-risk group. Health professionals should therefore utilize every opportunity to include direct family members in health education.

Ethics and Clinical Research

Abstract: Human experimentation since World War II has created some difficult problems with the increasing employment of patients as experimental subjects when it must be apparent that they would not have been available if they had been truly aware of the uses that would be made of them Evidence is at hand that many of the patients in the examples to follow never had the risk satisfactorily explained to them, and it seems obvious that further hundreds have not known that they were the subjects of an experiment although grave consequences have been suffered as a direct result of experiments described here There is a belief prevalent in some sophisticated circles that attention to these matters would “block progress” But, according to Pope Pius XII,1 “ science is not the highest value to which all other orders of values should be subordinated”

Refractive error blindness

Abstract: Recent data suggest that a large number of people are blind in different parts of the world due to high refractive error because they are not using appropriate refractive correction. Refractive error as a cause of blindness has been recognized only recently with the increasing use of presenting visual acuity for defining blindness. In addition to blindness due to naturally occurring high refractive error, inadequate refractive correction of aphakia after cataract surgery is also a significant cause of blindness in developing countries. Blindness due to refractive error in any population suggests that eye care services in general in that population are inadequate since treatment of refractive error is perhaps the simplest and most effective form of eye care. Strategies such as vision screening programmes need to be implemented on a large scale to detect individuals suffering from refractive error blindness. Sufficient numbers of personnel to perform reasonable quality refraction need to be trained in developing countries. Also adequate infrastructure has to be developed in underserved areas of the world to facilitate the logistics of providing affordable reasonable-quality spectacles to individuals suffering from refractive error blindness. Long-term success in reducing refractive error blindness worldwide will require attention to these issues within the context of comprehensive approaches to reduce all causes of avoidable blindness.

Maternal mortality at the end of a decade: signs of progress?

Abstract: Maternal mortality is an important measure of women's health and indicative of the performance of health care systems. Several international conferences, most recently the Millennium Summit in 2000, have included the goal of reducing maternal mortality. However, monitoring progress towards the goal has proved to be problematic because maternal mortality is difficult to measure, especially in developing countries with weak health information and vital registration systems. This has led to interest in using alternative indicators for monitoring progress. This article examines recent trends in two indicators associated with maternal mortality: the percentage of births assisted by a skilled health care worker and rates of caesarean delivery. Globally, modest improvements in coverage of skilled care at delivery have occurred, with an average annual increase of 1.7% over the period 1989- 99. Progress has been greatest in Asia, the Middle East and North Africa, with annual increases of over 2%. In sub- Saharan Africa, on the other hand, coverage has stagnated. In general, caesarean delivery rates were stable over the 1990s. Countries where rates of caesarean deliveries were the lowest — and where the needs were greatest — showed the least change. This analysis leads us to conclude that whereas there may be grounds for optimism regarding trends in maternal mortality in parts of North Africa, Latin America, Asia, and the Middle East, the situation in sub-Saharan Africa remains disquieting.

On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B. influenzæ

Abstract: 1. A certain type of penicillium produces in culture a powerful antibacterial substance. The antibacterial power of the culture reaches its maximum in about 7 days at 20o C. and after 10 days diminishes until it has almost disappeared in 4 weeks. 2. The best medium found for the production of the antibacterial substance has been ordinary nutrient broth. 3. The active agent is readily filterable and the name "penicillin" has been given to filtrates of broth cultures of the mould. 4. Penicillin loses most of its power after 10 to 14 days at room temperature but can be preserved longer by neutralization. 5. The active agent is not destroyed by boiling for a few minutes but in alkaline solution boiling for 1 hour markedly reduces the power. Autoclaving for 20 minutes at 115o C. practically destroys it. It is soluble in alcohol but insoluble in ether or chloroform. 6. The action is very marked on the pyogenic cocci and the diphtheria group of bacilli. Many bacteria are quite insensitive, e.g. the coli-typhoid group, the influenza-bacillus group, and the enterococcus. 7. Penicillin is non-toxic to animals in enormous doses and is non-irritant. It doses not interfere with leucocytic function to a greater degree than does ordinary broth. 8. It is suggested that it may be an efficient antiseptic for application to, or injection into, areas infected with penicillin-sensitive microbes. 9. The use of penicillin on culture plates renders obvious many bacterial inhibitions which are not very evident in ordinary cultures. 10. Its value as an aid to the isolation of B. influenzae has been demonstrated.

The treatment of epilepsy in developing countries: where do we go from here?

Abstract: Epilepsy is the most common serious neurological disorder and is one of the world's most prevalent noncommunicable diseases. As the understanding of its physical and social burden has increased it has moved higher up the world health agenda. Over four-fifths of the 50 million people with epilepsy are thought to be in developing countries; much of this condition results from preventable causes. Around 90% of people with epilepsy in developing countries are not receiving appropriate treatment. Consequently, people with epilepsy continue to be stigmatized and have a lower quality of life than people with other chronic illnesses. However, bridging the treatment gap and reducing the burden of epilepsy is not straightforward and faces many constraints. Cultural attitudes, a lack of prioritization, poor health system infrastructure, and inadequate supplies of antiepileptic drugs all conspire to hinder appropriate treatment. Nevertheless, there have been successful attempts to provide treatment, which have shown the importance of community-based approaches and also indicate that provision for sustained intervention over the long term is necessary in any treatment programme. Approaches being adopted in the demonstration projects of the Global Campaign Against Epilepsy--implemented by the International League Against Epilepsy, the International Bureau for Epilepsy, and the World Health Organization--may provide further advances. Much remains to be done but it is hoped that current efforts will lead to better treatment of people with epilepsy in developing countries.

Community-based treatment of advanced HIV disease: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy).

Abstract: In 2000, acquired immunodeficiency syndrome (AIDS) overtook tuberculosis (TB) as the world's leading infectious cause of adult deaths. In affluent countries, however, AIDS mortality has dropped sharply, largely because of the use of highly active antiretroviral therapy (HAART). Antiretroviral agents are not yet considered essential medications by international public health experts and are not widely used in the poor countries where human immunodeficiency virus (HIV) takes its greatest toll. Arguments against the use of HAART have mainly been based on the high cost of medications and the lack of the infrastructure necessary for using them wisely. We re- examine these arguments in the setting of rising AIDS mortality in developing countries and falling drug prices, and describe a small community-based treatment programme based on lessons gained in TB control. With the collaboration of Haitian community health workers experienced in the delivery of home-based and directly observed treatment for TB, an AIDS-prevention project was expanded to deliver HAART to a subset of HIV patients deemed most likely to benefit. The inclusion criteria and preliminary results are presented. We conclude that directly observed therapy (DOT) with HAART, ''DOT-HAART'', can be delivered effectively in poor settings if there is an uninterrupted supply of high-quality drugs.

Keeping clean water clean in a Malawi refugee camp: a randomized intervention trial

Abstract: OBJECTIVE: This study was undertaken to assess the ability of a water container with a cover and a spout to prevent household contamination of water in a Malawian refugee camp. METHODS: A randomized trial was conducted in a refugee population that had experienced repeated outbreaks of cholera and diarrhoea and where contamination of water in the home was found to be a significant cause of cholera. Four hundred Mozambican refugee households were systematically identified and followed over a 4-month period, one fourth of the households were randomly assigned to exclusively use the improved container for water collection. FINDINGS: Water flowing from the source wells had little or no microbial contamination although the water collectors quickly contaminated their water, primarily through contact with their hands. Analysis of water samples demonstrated that there was a 69% reduction in the geometric mean of faecal coliform levels in household water and 31% less diarrhoeal disease (P = 0.06) in children under 5 years of age among the group using the improved bucket. Regression models examining diarrhoea among under 5-year-olds confirmed the protective effect of the bucket and found that visible faeces in the family latrine and the presence of animals were significantly associated with an increased diarrhoeal incidence in children. CONCLUSION: Household contamination of drinking-water significantly contributed to diarrhoea in this population. Proper chlorination is a less expensive and more effective means of water quality protection in comparison with the improved bucket, but was unpopular and rarely utilized by the camp inhabitants.

Public-private partnerships for health: their main targets, their diversity, and their future directions.

Abstract: The global burden of disease, especially the part attributable to infectious diseases, disproportionately affects populations in developing countries. Inadequate access to pharmaceuticals plays a role in perpetuating this disparity. Drugs and vaccines may not be accessible because of weak distribution infrastructures or because development of the desired products has been neglected. This situation can be tackled with push interventions to lower the costs and risks of product development for industry, with pull interventions providing economic and market incentives, and with the creation of infrastructures allowing products to be put into use. If appropriately motivated, pharmaceutical companies can bring to partnerships expertise in product development, production process development, manufacturing, marketing, and distribution--all of which are lacking in the public sector. A large variety of public-private partnerships, combining the skills and resources of a wide range of collaborators, have arisen for product development, disease control through product donation and distribution, or the general strengthening or coordination of health services. Administratively, such partnerships may either involve affiliation with international organizations, i.e. they are essentially public-sector programmes with private-sector participation, or they may be legally independent not-for-profit bodies. These partnerships should be regarded as social experiments; they show promise but are not a panacea. New ventures should be built on need, appropriateness, and lessons on good practice learnt from experience. Suggestions are made for public, private, and joint activities that could help to improve the access of poor populations to the pharmaceuticals and health services they need.

Community-based noncommunicable disease interventions: lessons from developed countries for developing ones

Abstract: Community-based programmes for prevention and control of cardiovascular diseases (CVD) started in Europe and the USA in the early 1970s. High mortality from CVD in Finland led to the start of the North Karelia Project. Since then, a vast amount of scientific literature has accumulated to present results and discuss experience. The results indicate that heart health programmes have a high degree of generalizability, are cost-effective and can influence health policy. In the 1980s the focus of programmes expanded from CVD to noncommunicable diseases (NCD), mainly because of the common risk factors. Attention has now turned to promoting this approach in developing countries, where the prevalence of NCD is growing. Theory and experience show that community-based NCD programmes should be planned, run and evaluated according to clear principles and rules, collaborate with all sectors of the community, and maintain close contact with the national authorities. In view of the burden of disease they represent and of globalization, there is a great need for international collaboration. Practical networks with common guidelines but adaptable to local cultures in a flexible way have proved to be very useful.

Public-private health partnerships: a strategy for WHO

Abstract: Following early success with a number of high-profile partnerships, WHO is increasingly working with the private for-profit sector. In so doing, the organization finds itself in the maelstrom of a vibrant debate on the roles of public, civic, and commercial entities in society and on the appropriate modes of interaction among them. This paper examines WHO's involvement with the commercial sector, particularly in partnerships. WHO's approach to this sector is outlined and the criticisms levelled at public-private partnerships are reviewed. An indication is given of the steps recently taken by WHO to confront the concerns that have been expressed. The paper argues that partnership between WHO and the commercial sector is inevitable and that it presents considerable opportunities, but also significant risks, for the organization and for public health. A strategy is proposed for directing the debate on issues critical to WHO and its role in the promotion and protection of public health.

Noncommunicable diseases in sub-Saharan Africa: where do they feature in the health research agenda?

Abstract: There is no doubt that communicable diseases will remain the predominant health problem for the populations in sub-Saharan Africa, including adults, for the next 10-20 years. Concern has been expressed that the available resources to deal with this problem would be reduced by increasing the emphasis on noncommunicable diseases. The latter, however, already present a substantial burden because their overall age-specific rates are currently higher in adults in sub-Saharan Africa than in populations in Established Market Economies. There is also evidence that the prevalence of certain noncommunicable diseases, such as diabetes and hypertension, is increasing rapidly, particularly in the urban areas, and that significant demands are being made on the health services by patients with these diseases. To ignore the noncommunicable diseases would inevitably lead to an increase in their burden; the provision of health services for them would be largely undirected by issues of clinical and cost effectiveness, and their treatment and prevention would be left to the mercy of local and global commercial interests. Improved surveillance of all diseases within sub-Saharan Africa is needed in order to place noncommunicable diseases properly within the context of the overall burden of disease. Research is needed to guide improvements in the clinical and cost effectiveness of resources currently committed to the care of patients with noncommunicable diseases, and to direct and evaluate preventive measures.

Globalization and health: a framework for analysis and action

Abstract: Globalization is a key challenge to public health, especially in developing countries, but the linkages between globalization and health are complex. Although a growing amount of literature has appeared on the subject, it is piecemeal, and suffers from a lack of an agreed framework for assessing the direct and indirect health effects of different aspects of globalization. This paper presents a conceptual framework for the linkages between economic globalization and health, with the intention that it will serve as a basis for synthesizing existing relevant literature, identifying gaps in knowledge, and ultimately developing national and international policies more favourable to health. The framework encompasses both the indirect effects on health, operating through the national economy, household economies and health-related sectors such as water, sanitation and education, as well as more direct effects on population-level and individual risk factors for health and on the health care system. Proposed also is a set of broad objectives for a programme of action to optimize the health effects of economic globalization. The paper concludes by identifying priorities for research corresponding with the five linkages identified as critical to the effects of globalization on health.

Neonatal mortality of low-birth-weight infants in Bangladesh

Abstract: OBJECTIVE: To ascertain the role of low birth weight (LBW) in neonatal mortality in a periurban setting in Bangladesh. METHODS: LBW neonates were recruited prospectively and followed up at one month of age. The cohort of neonates were recruited after delivery in a hospital in Dhaka, Bangladesh, and 776 were successfully followed up either at home or, in the event of early death, in hospital. FINDINGS: The neonatal mortality rate (NMR) for these infants was 133 per 1000 live births (95% confidence interval: 110-159). The corresponding NMRs (and confidence intervals) for early and late neonates were 112 (91-136) and 21 (12-33) per thousand live births, respectively. The NMR for infants born after fewer than 32 weeks of gestation was 769 (563-910); and was 780 (640-885) for infants whose birth weights were under 1500g. Eighty-four per cent of neonatal deaths occurred in the first seven days; half within 48 hours. Preterm delivery was implicated in three-quarters of neonatal deaths, but was associated with only one-third of LBW neonates. CONCLUSION: Policy-relevant findings were: that LBW approximately doubles the NMR in a periurban setting in Bangladesh; that neonatal mortality tends to occur early; and that preterm delivery is the most important contributor to the NMR. The group of infants most likely to benefit from improvements in low-cost essential care for the newborn accounted for almost 61% of neonatal mortalities in the cohort.

Prevalence, awareness, treatment and control of hypertension among the elderly in Bangladesh and India: a multicentre study

Abstract: Objective To evaluate the prevalence, awareness, treatment and control of hypertension among elderly individuals in Bangladesh and India. Method A community-based sample of 1203 elderly individuals (670 women; mean age, 70 years) was selected using a multistage cluster sampling technique from two sites in Bangladesh and three sites in India. Findings The overall prevalence of hypertension (WHO–International Society for Hypertension criteria) was 65% (95% confidence interval = 62–67%). The prevalence was higher in urban than rural areas, but did not differ significantly between the sexes. Multiple logistic regression analyses identified a higher body mass index, higher education status and prevalent diabetes mellitus as important correlates of the prevalence of hypertension. Physical activity, rural residence, and current smoking were inversely related to the prevalence of hypertension. Among study subjects who had hypertension, 45% were aware of their condition, 40% were taking anti-hypertensive medications, but only 10% achieved the level established by the US Sixth Joint National Committee on Detection, Evaluation and Treatment of Hypertension (JNC VI)/WHO criteria. A visit to a physician in the previous year, higher educational attainment and being female emerged as important correlates of hypertension awareness. Conclusions Our findings emphasize the need to implement effective and low cost management regimens based on absolute levels of cardiovascular risk appropriate for the economic context. From a public health perspective, the only sustainable approach to the high prevalence of hypertension in the Indian subcontinent is through a strategy to reduce the average blood pressure in the population.

Estimates of maternal mortality for 1995.

Abstract: OBJECTIVE: To present estimates of maternal mortality in 188 countries, areas, and territories for 1995 using methodologies that attempt to improve comparability. METHODS: For countries having data directly relevant to the measurement of maternal mortality, a variety of adjustment procedures can be applied depending on the nature of the data used. Estimates for countries lacking relevant data may be made using a statistical model fitted to the information from countries that have data judged to be of good quality. Rather than estimate the Maternal Mortality Ratio (MMRatio) directly, this model estimates the proportion of deaths of women of reproductive age that are due to maternal causes. Estimates of the number of maternal deaths are then obtained by applying this proportion to the best available figure of the total number of deaths among women of reproductive age. FINDINGS: On the basis of this exercise, we have obtained a global estimate of 515,000 maternal deaths in 1995, with a worldwide MMRatio of 397 per 100,000 live births. The differences, by region, were very great, with over half (273,000 maternal deaths) occurring in Africa (MMRatio: > 1000 per 100,000), compared with a total of only 2000 maternal deaths in Europe (MMRatio: 28 per 100,000). Lower and upper uncertainty bounds were also estimated, on the basis of which the global MMRatio was unlikely to be less than 234 or more than 635 per 100,000 live births. These uncertainty bounds and those of national estimates are so wide that comparisons between countries must be made with caution, and no valid conclusions can be drawn about trends over a period of time. CONCLUSION: The MMRatio is thus an imperfect indicator of reproductive health because it is hard to measure precisely. It is preferable to use process indicators for comparing reproductive health between countries or across time periods, and for monitoring and evaluation purposes.

Sick individuals and sick populations. 1985.

Abstract: THE DETERMINANTS OF INDIVIDUAL CASES In teaching epidemiology to medical students, I have often encouraged them to consider a question which I first heard enunciated by Roy Acheson: `Why did this patient get this disease at this time?'. It is an excellent starting-point, because students and doctors feel a natural concern for the problems of the individual. Indeed, the central ethos of medicine is seen as an acceptance of responsibility for sick individuals. It is an integral part of good doctoring to ask not only, `What is the diagnosis, and what is the treatment?' but also, `Why did this happen, and could it have been prevented?'. Such thinking shapes the approach to nearly all clinical and laboratory research into the causes and mechanisms of illness. Hypertension research, for example, is almost wholly preoccupied with the characteristics which distinguish individuals at the hypertensive and normotensive ends of the blood pressure distribution. Research into diabetes looks for genetic, nutritional and metabolic reasons to explain why some people get diabetes and others do not. The constant aim in such work is to answer Acheson's question, `Why did this patient get this disease at this time?'. The same concern has continued to shape the thinking of all of us who came to epidemiology from a background in clinical practice. The whole basis of the case-control method is to discover how sick and healthy individuals differ. Equally the basis of many cohort studies is the search for `risk factors', which identify certain individuals as being more susceptible to disease; and from this we proceed to test whether these risk factors are also causes, capable of explaining why some individuals get sick while others remain healthy, and applicable as a guide to prevention. To confine attention in this way to within-population comparisons has caused much confusion (particularly in the clinical world) in the definition of normality. Laboratory `ranges of normal' are based on what is common within the local population. Individuals with `normal blood pressure' are those who do not stand out from their local contemporaries; and so on. What is common is all right, we presume. Applied to aetiology, the individual-centred approach leads to the use of relative risk as the basic representation of aetiological force: that is, `the risk in exposed individuals relative to risk in non-exposed individuals'. Indeed, the concept of relative risk has almost excluded any other approach to quantifying causal importance. It may generally be the best measure of aetiological force, but it is no measure at all of aetiological outome or of public health importance. Unfortunately this approach to the search for causes, and the measuring of their potency, has to assume a heterogeneity of exposure within the study population. If everyone smoked 20 cigarettes a day, then clinical, case-control and cohort studies alike would lead us to conclude that lung cancer was a genetic disease; and in one sense that would be true, since if everyone is exposed to the necessary agent, then the distribution of cases is wholly determined by individual susceptibility. Within Scotland and other mountainous parts of Britain (Figure 1, left section) (1) there is no discernible relation between local cardiovascular death rates and the softness of the public water supply. The reason is apparent if one extends the enquiry to the whole of the UK. In Scotland, everyone's water is soft; and the possibly adverse effect becomes recognizable only when study is extended to other regions which have a much wider range of exposure (r = -0.67). Even more clearly, a case-control study of this question within Scotland would have been futile. Everyone is exposed, and other factors operate to determine the varying risk. [FIGURE 1 OMITTED] Epidemiology is often defined in terms of study of the determinants of the distribution of the disease; but we should not forget that the more widespread is a particular cause, the less it explains the distribution of cases. …

Prevalence of impairments, disabilities, handicaps and quality of life in the general population: a review of recent literature

Abstract: OBJECTIVE: To determine the prevalence rates of morbidity in the general population through bibliographic research. METHODS: Articles relating to impairment, disability, handicap, quality of life and their prevalence in the general population, published between January 1990 and March 1998, were selected on the MEDLINE database. FINDINGS: The 20 articles retained out of 433 used 41 different indicators. Indicators of impairment, disability, handicap and low quality of life showed prevalence rates of 0.1-92%, 3.6-66%, 0.6-56% and 1.8-26% respectively, depending on age and the accuracy of indicators. The heterogeneity of the conceptual framework and insufficient recognition of the importance of indicator accuracy, the age factor and the socioeconomic characteristics of the studied populations impede reliable international comparison. CONCLUSION: Further standardization of indicators is therefore required. The revision of the International Classification of Impairments, Disabilities and Handicaps may make it possible to resolve some of the difficulties encountered.