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Key terms

  • Health- Physical, mental and social well-being, absence of disease
  • Infant Mortality:The number of babies who die before their first birthday in a year out of every thousand live births.
  • Mortality:Deaths. Case-mortality is the number of people dying from a disease divided by the number of people diagnosed with that disease.
  • Morbidity: Illness and disease. Some diseases are so infectious they must be reported by law, e.g. Yellow Fever and Cholera. Morbidity rate is the term sometimes used to describe the level of occurrence of illness or a particular disease.
  • Epidemic:Widespread outbreak of an infectious disease in a locality
  • Pandemic:An epidemic over a large region or across the world 
  • Infectious Disease: Can be transmitted between people, AIDS is a behavioral infectious disease
  • Non-Communicable Disease:  Cannot be passed from person to person.. e.g. CHD and Cancer
  • Vectors: Organisms that spread disease … e.g. bacteria and viruses

The population of the world is getting bigger and in most places older as we know. This has massive impacts on health care because it is expensive. A major challenge for the future for all countries will be trying to improve both access to healthcare and quality of healthcare.

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Global distribution- Mortality and Morbidity

There is a clear divide showing higher crude death rates in LICs than HICs. The highest rates are in Sub- Saharan Mortality- Africa (e.g. Ethiopia) and Afghanistan. Infant Mortality is falling in most countries but remains high in the same Least Developed Countries (LDCs). In HICs and some MICs (e.g. China and India) life expectancy continues to increase but demographic ageing means crude mortality rates can be higher than expected because there are higher percentages of elderly people in those countries. An exception is Saudi Arabia and other Gulf countries which have low crude death rates. This is because they have a young population and high life expectancy. Six diseases cause 90% of infectious disease deaths in the world: HIV    Pneumonia       Tuberculosis        Malaria      Measles       Diarrhea

Pneumonia kills more children than any other infectious disease, and 99% of the deaths occur in developing countries.

Morbidity- Levels of illness and disease vary enormously across the world but there is a clear pattern of: 1.  Higher levels of preventable infectious disease in LICs and the rural populations of MICs such as India and Pakistan e.g. levels of TB, Malaria and HIV/AIDS are much higher in Sub Sahara Africa and South Asia due to:

  • Malnutrition
  • Lack of clean water and safe sanitation
  • Poor access to healthcare
  • Tropical conditions which create a wider range of vectors

2.   Whereas in HICs, and increasingly cities in MICs (e.g. Mumbai), non-communicable diseases are much more common, many of these are strongly linked to behavior and lifestyle choices; diet, exercise levels and smoking/drugs/drinking/stress- e.g Obesity, CHD, Cancer and Type 2 diabetes.

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Distinguish between Mortality and Morbidity

Mortality refers to deathswithin the population. It is measured by the crude death rate; the number of deaths per 1000 population per year or by age specific rates such as the infant mortality rate

In contrast, morbidity relates to the ill-healthof the population. Information on numbers who are ill can be collected from a register of certain infectious diseases, such as cholera, or from census data when people have to categorise their general state of health and whether they have a limiting long-term illness. Morbidity can also be measured using DALYs – disability adjusted life years.

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Communicable disease- HIV

Data unreliability of HIV/Aids numbers- Medical records are confidential so access can be restricted- Many people are unaware that they are infected- Social stigma means that many do not report the illness until later stages – especially in Sub Saharan Africa- AIDS is not always on death certificates, could be pneumonia or another opportunistic disease

There are some suggestions of African governments overestimating numbers to get more aid, although Kenya was one accused of under-estimating because of feared effects on tourists.

Global Distribution- There are thought to be around 35 million people infected with the HIV pandemic worldwide. Sub Saharan Africa has by far the highest rates accounting for 75% of world deaths from the disease last year. In Botswana over 20% of the adult population are infected. The high levels in SSA are mainly due to male promiscuity.

However, along with other Islamic regions, North Africa has low infection rates. In Asia infection percentage rates are generally low but overall numbers are high in India and China because of their large populations. Only Thailand has an adult infection rate above 1%. South America on average has low infection rates but the Caribbean has the second highest infection rates outside of SSA.

In High Income countries in North America, Western Europe and Australasia infection rates have slowed down as high risk groups have been effectively targeted. However there has been a worrying increase in infections among young heterosexuals in the UK.

Finally recently Eastern Europe has seen a considerable increase in infections among intravenous drug users. It is difficult to get accurate data due to a range of complications, including many people being deliberately not diagnosed.



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HIV/AIDS- impacts on health and lifestyle

The main health impact of HIV/AIDS is illness and eventual death; around 35 million worldwide are infected and it’s the leading cause of premature death in economically active age groups. The disease attacks the immune system by reducing a person’s CD4 count, leaving them vulnerable to opportunistic diseases such as TB.

This can cause difficult or painful swallowing, severe and persistent diarrhoea, weight loss and extreme fatigue. Mental symptoms include confusion, forgetfulness and severe headaches, but mental health issues also result from the psychological stress of dealing with diagnosis.

However in HICs the success of ARV medication and raised awareness of healthy lifestyles has significantly increased life expectancy and reduced symptoms in patients.

Lifestyle can be severely affected because of social stigma. Even in HICS people can face discrimination in personal relationships, careers and access to life insurance.

However discrimination, especially against women, in sub Saharan Africa (e.g. Zimbabwe) is often extreme; including being abandoned by partners and direct family. Sometimes women are denied access to their own children; causing themselves severe distress but often resulting in child neglect too. Infected children’s lifestyles can be furthered disadvantaged by being denied access to school and by taking on the responsibility of caring for siblings and/or parents at a young age.    

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HIV/ADIS- impact on economic development

In the worst affected parts of sub Saharan Africa HIV has slowed down economic development due to a range of linked factors: An increase in mortality and sickness absence of economically active adults has led to staff shortages in many key industries and services including education and healthcare. In 2007 Zambia lost 3000 teachers this results in a poorly educated workforce which makes it harder for the region to compete in a globalizing world economy demanding transferable skills.  Orphans and children taken out of school, often due to discrimination, make this problem worse.

 Loss of agricultural workershas led to a fall in crops for export meaning a reduction in much needed foreign income.In all affected counties the increased demand for healthcare, medicine and other support mechanisms puts a massive financial burden on national governments.

Rising infection ratesin Russia means a higher dependency ratio to pay for the care of both young and old dependents, but because it is economically active adults dying there is less tax being paid to do this.

 Nigeria is Africa’s biggest economy which has a predicted growth rate of 7% per year for the next decade. However the reduction of the work force and costs of treating an estimated 3.5 million infected people means the country is not reaching this prediction. Already 1.5 million people need expensive ARV treatment.

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non- communicable disease- CHD

Global distribution-  Traditionally High Income Countries in Europe, North America and Australasia have had the highest levels due to long life expectancy and high blood pressure; linked to unhealthy lifestyles: high fat and sugar diets and lack of exercise. However in the last decade more successful treatment and increased awareness of healthy living has led to significant reductions.

At the same time however there have been sharp increases in Eastern Europe; Russia which loses more than 30 DALYs per 1,000 population, has the highest rates in the world; linked to smoking, substance abuse and increasing poverty.

In many LICs and MICs levels of CHD are still low (especially South America and China) however recent increases in life expectancy and sedentary, westernized lifestyles of the growing middle classes in urban India, the Middle East and North Africa has seen sharp increases in the disease; in sharp contrast to poorer rural areas. Due to these trends it is anticipated that over 80% of the future increases in CHD will be in LIC and MICs.

There are also differences within countries. In the UK wealthier residents in the South have lower levels on average, a pattern reflected in most HICs; linked to lower quality diets and higher levels of drinking and smoking in lower income groups.

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Health and Lifestyle impacts.

Health- CHD is the most common cause of premature death in the UK, around 2 million people are diagnosed and it accounts for around 75,000 deaths every year. The coronary arteries become partially blocked with atheroma (plaque); this reduces the oxygen supply to the heart and leads to tight chest pains called angina. Further blockages or clots can lead to a heart attack which can be fatal if not treated immediately. CHD can also damage the heart muscle which can cause palpitations; an abnormal heart beat. Severe damage can stop the heart beating causing a cardiac arrest. 

Patients can also develop heart failure when the heart becomes too weak to pump blood around the body. This can cause fluid to build up in the lungs, making it increasingly difficult to breathe and cause swelling in their feet, ankles and legs. Increased breathlessness can limit a person’s mobility which puts them at greater risk of obesity which in turn puts more pressure on the heart  Mental healthissues can also occur due to the psychological effect of having a heart attack, the thought that it could happen again and worry about effects on family. Some people become depressed or anxious and need medication, counselling or relaxation therapy. In the UK CHD patients are 3 times more at risk of clinical depression

Lifestyle-One impact is patients may need to adjust to long term medication, such as aspirin or statins. For some people diagnosis can trigger lifestyle improvements; following medical advice they may:  reduce or give up smoking and drinking- eat a healthier diet- exercise more regularly  In more severe cases people may have to adjust lifestyles by reducing work hours or finish work completely.  Increased breathlessness can restrict mobility and activity; in more extreme cases keeping people housebound. Issues over activity can have psychological implications, not being able to play with kids, grandkids or help out with housework can leave sufferers feeling worthless and frustrated.  However close family members are often affected too. Many act as carers which can impact on their quality of life; children and partners live in anxiety of heart attacks. In some cases the ‘burden’ of being a carer can even lead to feelings of resentment. However medical advances have greatly reduced lifestyle impacts in recent years.

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Economic Impacts

Firstly there are economic costs to individuals as they may lose earnings and need to pay for prescriptions and treatment. If that person needs to take time off work employers will be affected putting a high cost on U.K businesses and organisations due to lost productivity and sickness pay.

 Sometimes family members need to take absence from work to act as carers if the patient’s condition becomes severe. This ‘informal care’ cost the European Union £2.5 billion last year.There are enormous costs to the country in various benefits paid to CHD patients, including disability and earlier pension payments.

 National preventative programmes such as Healthy Eating in schools are also expensive. The costs of CHD treatment, including by-passes, angioplasty and expensive statins and beta blockers, puts a massive financial strain on the NHS. This puts a strain on the national budget and is part of the reason why retirement ages and national insurances are increasing, therefore impacting economically on the rest of the population.

 Because life expectancy is increasing in the U.K. the frequency of CHD is also increasing which means this financial burden on the country is also increasing and diverting funding away from other important areas such as education and deficit reduction. The British Heart Foundation estimates heart disease in the U.K. is thought to cost the country around seven billion pounds a year.

On the other hand the level of care, medical intervention and development and distribution of new medicine does create many jobs in the economy.

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Food & Health

Technological advances in intensive farming means there is more than enough food produced in the world every year to feed everyone. However we also know that not everyone is getting access to this food. The global distribution is very uneven. There are an estimated 30 million people a year die from starvation and another 800 million who suffer from chronic malnutrition. We know that many of these people live in the Sahel and we also know, from our work on deserts, that desertification is making their poverty worse. We also know that the cruel fate for many of these people is that their desperate struggle to feed themselves leads them to unsustainable farming methods which increases desertification and ultimately therefore reduces the potential to provide food. All of this, of course, has dramatic impacts on health and well-being.

Malnutrition covers a range of conditions that can result if people don’t have a healthy balanced diet. This can be under-nutrition when people are not getting enough food (calorific intake) over a sustained period of time, leading to dangerous weight loss and ultimately death, often due to periodic famine. This can leave people vulnerable to disease because of weakened immunity. It can also lead to a deficiency disease such as anemia. Malnutrition also includes over-nutrition, which can lead to obesity. It includes diets that may not lead to under or over nutrition but can have vitamin deficiencies such as Vitamin D which is a cause of rickets.

Famine occurs when there is not enough food in a particular place for a particular time which can lead to under-nutrition. The UN declares a famine if 20% of the population has access to less than 2,100 calories a day and acute malnutrition for children reaches 30%. For some this leads to starvation and ultimately death. It has the greatest impacts on the most vulnerable in society. Famines can be a result of:

Natural events:  Drought    Natural Hazards OR Human factors: Conflict     Population pressure     Unsustainable Land Management

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Obesity & Somalia famine

Obesity is an excessive build-up of fatthat can impact on an individual’s health and well-being. This usually means a person’s weight is too high for their particular heightgiving them a high BMI (body mass index) which takes into account the ratio of weight and height. A BMI of 30.0or more is considered as ‘obese’.

Somalia Famine 2011-  CAUSES

Physical- Drought

2011 was the driest in 60 years as all of the seasonal rains failed, partly a result of the La Nina global climate effect this led to a 70% drop in maize and sorghum harvests in the South. It also led to cattle dying which reduced milk availability; this is the only source of protein for many families and significantly contributed to under-nutrition. Because farming in the region provides few surpluses even in a good year stocks of food were already low at the beginning of 2011.

Also long term desertification of the region has reduced soil fertility which further limits the amount of food that can be produced.

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Somalia famine 2011- Causes

However desertification is also partly caused by people, through unsustainable farming and deforestation which leads me in to the human causes of the famine …. 

Human- The collapse of farming in the region led to: Shortages of food which reduced availability and pushed up prices- Rural unemployment increased poverty people couldn’t afford to buy food however this was made worse when global food prices increased in 2011 as Somalia is heavily dependent on imports showing external forces are equally as important.

 A major issue, some say the biggest factor, was conflict. Fighting between various groups in the country led to extreme poverty for people living in Internally Displaced Camps. However because southern Somalia was now mostly under control of Al Shabaab foreign aid was cut off, increasing under-nourishment as thousands of people relied on NGOs for food supplies and medical help.

In a report on the 2011 Somalia crisis Red Cross said:

“the drought was a natural disaster, the famine was man-made”

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The 2011 famine in Somalia caused extreme impacts. The failure of seasonal rains and increasing conflict in the South of the country led to: shortages of food as Maize and Sorghum harvests fell by 70% & Increased rural unemployment. This forced thousands of people into ‘distress migration’ to seek help in IDP camps and refugee camps over the border in Kenya. In total 1.1 million people were displaced.

Social Impacts: Impacts on health in the camps and worst hit villages were severe. In total 260,000 people died; half of these children under 5 significantly increasing child mortality levels. The death of livestock from water shortages drastically reduced the availability of milk which is the only source of protein for many farming families this further contributed to malnourishment and vitamin deficiencies led to an increase in rickets, scurvy and beri beri.  On top of this poor sanitation in the camps spread infectious disease, including cholera and typhoid. Other social pressures impacted on quality of life, a lack of education funding and deep insecurity over violence in the camps

The fall in supply and increase in demand for food resulted in crippling economic impacts. Farmers who lost money from reduced crop and cattle sales could no longer afford to feed their families. This situation was made much worse as Somalia became more dependent on imported food, world food prices increased in 2011 showing how impacts can be further influenced by external factors. A major economic impact was the growing dependency of Somalian people on foreign aid and help from NGOs such as the Red Cross however because the south of the country was now mostly under control of Al Shabaab a lot of aid money and food supplies were diverted and never reached those most in need; mostly the Bantu ethnic group. Like in most famines it was the poorest, most vulnerable people who died or suffered most. In this case the peasant farmers who lost income and couldn’t afford the rising cost of food; and the Bantu tribes people who were discriminated against by the Al Shabaab rebels.

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Health effects- Under nutrition

Starvation begins when an individual has lost about 30% of normal body weight. Once the loss reaches 40% death is almost inevitable. Reducing calories to a very low level: 

  •  Prevents the body from obtaining proper nutrients and energy.
  • As a result, fatigue is common because the body does not have ample energy to function.
  • The body breaks down muscles to be used as fuel as it attempts to keep vital organs like the heart and lungs functioning.
  • Vitamin and mineral deficiency results and can lead to anaemia, diarrhoea, rashes, edema and heart failure.

 Early symptoms include irritability and hyperactivity

Atrophy (wasting away) of the stomach weakens the feeling of hunger, since the perception is controlled by the percentage of the stomach that is empty.

Victims of starvation are often too weak to sense thirst, and therefore become dehydrated causing dry and cracked skin

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Management stratagies for periodic famine

When famine hits a region there firstly needs to be short term aid to provide emergency relief.  In the 2011 famine in Somalia this was mostly carried out by NGOs including CAFOD, OXFAM and the Red Cross. This aid mostly involves distributing water and food supplies and providing medical intervention. Local health posts were set up to avoid treks to feeding centres which provided emergency therapeutic nutrition for those too dehydrated to cope with solid food.

However because southern Somalia was mostly under control of Al Shabaab foreign aid was cut off to the area which limited the success of these efforts. More recently in the Horn of Africa aid agencies consider food aid to be a last resort, donating cash or vouchers instead, which is less disruptive to local farmers, stabilizes markets and helps guarantee local incomes.

The most effective strategies come from long term planning which focus on preparing communities to prevent and deal with drought before it strikes.

  • Investment in irrigation and wells to harvest the seasonal rains.
  • Improving and increase grain stores.

Finally many people believe the problems can only be improved long term if people in the Horn of Africa and South Asia are taken out of the poverty trap through fairer international trade agreements.

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Cause of obesity

The principal cause is eating too much and not getting enough exercise.  Unhealthy eating includes: eating processed or fast food that is high in saturated fats. not eating fruit, vegetables and unrefined carbohydrates, such as wholemeal bread and brown rice drinking too much. alcohol - alcohol contains a lot of calories, and heavy drinkers are often overweight. eating out a lot - as you may have a starter or dessert in a restaurant, and the food can be higher in fat and sugarcomfort eating - if you feel depressed or have low self-esteem you may comfort eat to make yourself feel better

 Lack of physical activity is related to: sedentary jobs that involve sitting at a desk for most of the day, dependence on transport instead of walking or cycling, sedentary leisure e.g. TV, computer games and PCs

However it is becoming increasingly recognized that obesity is linked to societal issues and not just individual responsibility. Food manufacturersand providers are blamed for aggressive and misleading marketing and lack of transparency on labelling. Governments are criticized for not doing enough to regulate this. Also fresh fruit and vegetables often work out more expensive than less nutritional processed and take away foods. Leading nutritionists Professor Jebb says that: “Obesity is a consequence of modern life as well as the human body’s ability to store fat”

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Obesity impacts

Around a quarter of adults and 10% of children in England are obese. About 2 billion people – nearly 30% of the population of the planet – are overweight or obese and although the rise in obesity rates seems to be slowing in some countries, it has yet to be reversed in any.

Short-term day-to-day problems include:

  • breathlessness
  • increased sweating                                       
  • snoring                                                                       
  • difficulty sleeping                                        
  • lethargy - feeling very tired
  • back and joint pains.

Long term problems

  • High blood pressure and cholesterol levels.

Psychological problems- Low self-esteem, a poor self-image, low confidence levels, feelng isolated in society and reduced morbility.

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Treatment and management of obesity

Prevention is about trying to get people to exercise more and eat healthily: Government Prevention Strategies. Change 4 Life scheme run by the NHS – raises awareness about healthy eating and exercise opportunities

Investing in leisure facilities in the public sector to give local people exercise opportunities – Wigan:   Shape Up Trim Down Encouraging cycling/walking to work- London/Liverpool: Cycle Hire

Extra funding to schools to pay for healthy eating programmes and after school sports facilities

Food Industrystarting to be more responsible:

 Reducing the fat, sugar and salt content of processed foods- Reducing portion sizes in ready meals- Offer more nutritious choices 

Treatment- Medication: only one has proved to be both safe and effective: Orlistat. The most successful treatment in terms of maintaining weight loss has been through a range of bariatric surgeries, including gastric bands and gastric bypasses

However:The British Medical Journal states that tackling obesity is not just about trying to change individual’s behavior – it highlights that obesity is a societal issue; that is deeply rooted in our modern lifestyles and culture, and therefore needs a societal response. The suggestion is that for too long there has been a blame culture focused on the individual, whereas the responsibility also lies with governments, the food industry and even employers.

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A Transnational Corporation is a company that operates on an international scale and is therefore part of the process of globalisation.

GlaxoSmithKline (GSK) is a British TNC which operates throughout the world. It employs around 110,000 people worldwide, including over 40,000 in sales and marketing.

GSK mostly sells branded drugs in MEDCs, 45% of sales are in the U.S.A, but it operates in 70 countries. Products range from consumer goods like Ribena and Sensodyne to anti- biotics such as Amoxil. The patent on these antibiotics means they are expensive and it is illegal to sell generic alternatives without a license; making many of these products unaffordable in LICs.

However the company has cut the prices for all drugs in the 50 least developed countries to no more than 25% of the levels in the UK and US and made drugs (including ARVs) more affordable in MICs such as Brazil and India. Also it reinvests 20% of profits in the LDCs to help pay for hospitals, clinics and staff and continue tropical disease research at its dedicated institute at Tres Cantos in Spain.


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TNC- Tobacco

The marketing and selling of tobacco products by TNCs such as British American Tobacco has serious health consequences across the world. he associated health risks of smoking include a 500% increase in the risk of coronary heart disease and a significant risk of lung and many other cancers. Smoking also increases the risk of having a stroke, because of damage to the heart and arteries to the brain.

 According to WHO figures, smoking is responsible for approximately five million deaths worldwide every year. By 2020, the WHO expects the worldwide death toll to reach 10 million, causing 20% of all deaths in lower income countries.A major issue is that as smoking is on the decline in most HICs (except Eastern Europe) the TNCs are targeting the emerging markets of LICs, such as India and Vietnam, where population is increasing, tobacco use is on the increase and there are weaker regulations on tobacco advertising.

On the other hand BAT points out that it paid out £30 billion in worldwide taxes last year which can be used by governments to help meet health care costs. Research shows however that the impact of smoking on health costs more than tax revenues collected.

in Malawi the best quality land is being bought up and used by the tobacco companies.  Pay and conditions for workers on the farms are notoriously poor. tobacco plantations use machinery rather than labour intensive techniques; which maintain high unemployment and poverty in the region.But equally as important is that this land grabbing denies locals the best land for growing food who are then forced on to marginal land. Also the use of firewood to cure the leaves after harvesting has led to dramatic deforestation in the country making fuel wood more scarce and further impoverishing local peasant farmers.

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Health in world affairs

One political issue is the contrast between health care and outcomes between countries. Although the USA is an extremely wealthy country its standards of healthcare vary considerably among citizens. For the majority who can afford private insurance provision is high quality. However 50 million residents are not insured and rely on substandard government services. As a result overall life expectancy and morbidity rates are not that different to nearby Cuba which has a much lower GDP. As a consequence President Obama is trying to make health reforms in the USA but is facing strong opposition from political and commercial opponents.In the UK at the moment there is also public concern about the government’s reforms to the NHS and in particular a move to privatisation of certain services.

Another world issue is the devastation of AIDS in sub-Saharan Africa and how the social and economic impacts are holding back much needed development leaving many in the region reliant on international aid. However the role of pharmaceutical TNCs in this, another major world health issue, has changed recently as copyright laws have been relaxed so that people can receive cheap generic anti-retroviral medication to prolong life expectancy. This is seen as real progress by many people as TNCs such as GSK have been previously criticised for concentrating research and investment on affluent diseases in MEDCs such as CHD.

Finally I think another issue is the important work done by the World Health Organisation as part of the United Nations in recent years. They have been a major force in combating communicable and non- communicable disease across the world with initiatives like the World Vaccine Week in April this year which boosted immunization of preventable diseases in 180 countries. In recent years it has been influential on government policies in various countries. A good example of this was the smoking ban introduced in the UK in 2007 which has helped to reduce heart attacks by 15% and significantly reduced the risks of passive smoking.

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Regional health variations

Health and illness varies across the UK. There is however a clear north/south divide in a range of indicators e.g. people with a limiting long term illness.  Whilst the 10 local authorities with the lowest morbidity rates are all in the South of England, 7 out of 10 with the highest are in Scotland.However some of the widest variations exist within regions, particularly between inner cities and suburbs. The South East of England is a good example with very high levels of morbidity in inner London compared to some of the healthiest areas of Britain in the surrounding Home Counties. Wherever you go there is often a strong correlation between health and wealth.

INCOME- The North on average is poorer than the South and social behaviours associated with lower income groups can explain more health problems: higher levels of smoking and drinking and less exercise are major causes of CHD, strokes and various cancers, all of which are overrepresented from the national average in northern cities like Manchester and Glasgow. Also poor quality diets can lead to obesity and type 2 diabetes. People often struggle to afford fresh fruit and vegetables but increasingly the rising cost of gas and electricity is reducing domestic cooking times meaning more takeaway and convenience foods which are often high in fat and sugar.

OCCUPATION TYPE-  in terms of jobs areas such as the North East and Midlands have higher than national average asbestos related diseases due to previous manufacturing. Over 2,000 people a year are still diagnosed with the disease.  Also in the NE call centre work is linked to high levels of RSI.


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Regional health variations continued

AGE- In Salford young people find it difficult to access exercise facilities, local councils have sold off playing fields to property developers. Many cannot access indoor facilities because of age restrictions or afford expensive private health clubs. Also many parents don’t like their children walking to school because of traffic and gang culture; all factors behind higher levels of obesity.On the other hand areas with elderly residents such as Lytham have higher than national average levels of geriatric conditions, such as dementia, osteoarthritis and CHD. This can put severe pressure on the local NHS.

INCOME- In contrastwealthier individualsbenefit from private healthcare from providers such as BUPA, where standards of diagnosis and treatment can be better, but in particular waiting times for treatment are much less. Statistics show higher percentages of private health care insurance in the South East, but also in other areas of wealth such as Cheshire and Edinburgh, so the North/South divide is not always consistent.

ENVIRONMENT- Social environment:   Inner City areas with high levels of crime and fear of crime, together with few recreational and social opportunities, all contribute to increased stress levels. Stress in itself is linked to a range of conditions from heart disease to clinical depression. Physical environments:The recently published Health Atlas (2014) shows: More skin cancers in the SW because it has the highest sunshine hours in the UK.  Levels of air pollution also vary, with urban areas showing higher levels of  respiratory conditions such as asthma due to traffic and building emissions. In London however the cycle hire and congestion charge schemes have led to a slight reduction in these conditions

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