Advances in medical discipline as well as technology and demographic changes pose widespread challenges to nations in their preparedness for the future. Health science and scientific medical care are part of a worldwide financial system, and are being made more and more cohesive. It is easier said than done to deny aspirations in matters affecting health and life itself, and this issue is at the core of the dilemma facing not only the developing nations but also the most advanced and richest nations of the world. Whether it is a useful drug for HIV-positive pregnant women in South Asia or transplanted organ in more affluent nations, we all face the realities of economic constraints.
Medical care is more than ever a globalised system not only in biomedical science and communication, but also in the ways developments in this arena are conceived and marketed. The history and culture of each community have an important role in the acceptance and use of varying approaches to health. But the nature of advances in science and technology, growing tensions between possibilities and cost, and demographic changes throughout the world with increasing longevity and falling fertility pose many shared challenges.
SOUTH ASIA: Throughout the world, populations are aging, some much faster than others. About one-tenth of the South Asia's population is presently 65 years and older. In just 15 years, the elderly subgroups in India, Pakistan and Bangladesh will approach one-quarter of their populations. India has a longer period to anticipate this kind of transformation but when its largest age cohorts, between the ages of 30-50, approach their older years, it too can anticipate challenging social changes. More important than the proportions of the elderly are those who are 70 years or more who we increasingly refer to as the old-old and the oldest-old. Persons in these age groups have more disabilities and limitations and are more dependent than the younger groups on family and community supports. This old population is increasing in most countries, and with growing longevity typical of South Asian populations, a significant growth in the number of the frailer and more dependent individuals can well be anticipated.
Health care costs for older populations are substantially higher than for other age groups and can pose economic challenges, if expensive medical interventions are increasingly adopted. Countries like India that have 'medicalised' old age, face greater difficulties in dealing with long-term care than advanced countries that have more well-developed social care models for the elders. One way of accommodating elderly persons with significant limitations in performing usual activities is the nursing home, a residential facility providing nursing care 24 hours a day and assistance with daily living activities. Such facilities are used differently by nations and reliable comparisons across countries are difficult. Many factors affect such patterns, and here culture has a powerful role. Traditionally, in almost all countries, most of the responsibility falls on family members but throughout the world family size is decreasing, women are more involved in the workforce, divorce rates are higher and there is increased geographic mobility. Thus, even in countries with the strongest traditions of family responsibility, policy makers have had to explore alternatives. The preferences of the elderly themselves are a powerful force in many countries, and there is a strong feeling of many elders to avoid institutional living.
Thus, in India and Bangladesh, admission to nursing homes is falling despite increase in the oldest-old population. Part of this trend reflects the strong value of maintaining as much independence as possible and receiving care in the least restrictive setting. New technologies also make it possible to provide many medical services in home-like settings. Thus we are witnessing a substantial growth in new life care communities, assisted living facilities, supervised housing, care residences, adult day-care, foster care and a range of new integrated community programmes.
Policy makers in South Asian countries with aging populations worry about the future maintenance of their retirement and social security systems as the proportions of retired persons grow relative to the size of the working population. Retirement in South Asian countries occurs quite early relative to the length of life from South Asian countries which suggests that life is not only extended but also the elderly at any age are more robust and have greater functional capacity than in earlier periods. Thus, there is much interest in extending the period in which people remain in the workforce, particularly in countries with low unemployment. Incentives embodied in retirement and pension systems in South Asian countries have little influence on the extent of employment of the elderly. In South Asia, only about one-quarter of the males work at the age of 65 and more. The important role of social policy here is abundantly clear. Patterns of disease in modern nations have also changed remarkably with degenerative and behavioural factors taking precedence over infections and other communicable diseases. As in South Asia, major causes of death are now from cancer, cardiovascular and pulmonary disease. A large proportion of all deaths are preventable until old age if social, environmental and behavioural influences can be modified. Major risks worldwide now come from smoking, poor nutrition, high risk-taking in sexual and other behaviours and accidents. Violence and suicide are also increasingly common causes of death reflecting high levels of psychological morbidity and distress and the erosion of family and community life.
POVERTY AND HEALTH CARE: Throughout the world, poverty is still the major determinant of ill health. Mortality with tuberculosis, malaria, AIDS and other communicable diseases is taking an extraordinary toll in addition to the factors already noted.
The developed nations cannot be complacent about the traditional killers with the increasing mobility of population worldwide and the growing number of antibiotic resistant infections associated with the casual use and misuse of antibiotics. There are many disease challenges but South Asian nations, especially, will have to give their attention to the prevention of disability and functional maintenance and restoration. India still faces the issue of how best to respond to the growing expectations and demands for health care. The potential is there to spend much more, but such increases must be weighed against opportunities in other valued areas.
The fact that a region attains appreciable rates of infant mortality and adult longevity is noteworthy, but this has more to do with overall standard of living than with medical care. The value of medical care is rarely measured solely by mortality statistics, since the role of much of medical care is to enhance function and reduce distress. Thus, the more relevant question is the extent to which the population at any age is free of disability and has a good level of function in the activities of daily living and a sense of subjective well-being. Here such medical procedures as the removal of cataracts that restore sight and the replacement of joints that allow physical mobility contribute to health in important ways not measured by mortality. This is also the case for many new pharmaceuticals that bring significant relief from physical distress unrelated to mortality such as relief of pain from arthritis or reduction of anxiety or depression. Communication across national boundaries contributes to rising public expectations and increased pressure to spend more for health care. The biomedical industries and pharmaceutical companies now actively promote their products directly to consumers encouraging them to create new demands on their hospitals, doctors and other health professionals.
These range from advertising new expensive models of machines, such as open air-type models, directly to the public as a way of indirectly pressurising hospitals to purchase such machines to widespread advertising of prescription drugs. In India, it is not uncommon for consumer groups to form coalitions with pharmaceutical companies to pressurise the government to increase prescription coverage. The billions of dollars spent in promoting these medical products inevitably and importantly affect national systems of care. Physicians in India were being recruited away from state practice with higher salaries as international pharmaceutical company salesmen. South Asian Nations find it increasingly difficult to insulate themselves from international consumer comparisons as illustrated by the continuing pressures on the National Health Service that has up till now devoted a lower proportion of medical care than their western counterparts.
MEDICAL GLOBALISATION: In making these generalisations about medical globalisation it should be clear that culture and local politics remain extremely powerful. There are no automatic or inevitable changes outside each nation's unique history and experience, and alternative pathways are always possible. The forces of medical globalisation, however, make certain trends more likely. Every nation must decide how to allocate public expenditures among varying priorities and responsibilities, the extent of public and private responsibilities for health care, and the types of services that constitute the health scheme. All nations cover basic preventive, ambulatory and hospital services, but there is a great variety in public perception of other important services and products such as prescription drugs. Tradition and culture help define whether health care includes access to spas and natural treatments, respite services, chiropractic, traditional and alternative medicines, behavioural health and substance abuse services, among many others. There are also a range of views about whether services that enhance the quality of life such as viagra and related products for impotence or in-vitro fertilisation are appropriate responsibilities of public health care systems and at what level. More fundamentally, each nation must decide how to balance individual responsibility, privatisation and competition with the need for helping those less fortunate and for social solidarity. Excessive individualism is associated with large health inequalities-a growing concern in many countries. Every decent system provides a safety net for those incapable of meeting their own needs. Beyond this, universal health coverage is a widely shared value that contributes to social solidarity.
Dr. Mohammad Rajja is Medical Doctor serving with Narayani Sub Regional Hospital, Birgunj, Nepal.
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