Morbidity.

Modern state of population health of Ukraine

 

CONCEPT OF HEALTH

Health is a common theme in most cultures. In fact, all communities have their concepts of health, as part of their culture. Among definitions stilt used, probably the oldest is that health is the "absence of disease". In some cultures, health and harmony are considered equivalent, harmony being defined as "being at peace with the self, the community, god and cosmos". The ancient Indians and Greeks shared this concept and attributed disease to disturbances in bodily equilibrium of what they called "humors".

Modern medicine is often accused for its preoccupation with the study of disease, and neglect of the study of health. Consequently, our ignorance about health continues to be profound, as for example, the determinants of health are not yet clear; the current definitions of health are elusive; and there is no single yardstick for measuring health. There is thus a great scope for the study of the "epidemiology" of health.

Health continues to be a neglected entity despite tip service. At the individual level, it cannot be said that health occupies an important place; it is usually subjugated to other needs defined at more important, e.g., wealth, power, prestige, knowledge, security. Health is often taken for granted, and its value is not fully understood until it is lost. At the international level, health was "forgotten" when the covenant of the League of Nations was drafted after the First World War. Only at the last moment, was world health brought in. Health was again "forgotten" when the charter of the United Nations was drafted at the end of the Second World War. The matter of health had to be introduced ad hoc at the United Nations Conference at San Francisco in 1945.

However, during the past few decades, there has been a reawakening that health is a fundamental human right and a ^world-wide social goal; that it is essential to the satisfaction of basic human needs and to an improved quality of life; and, that it is to be attained by all people. In 1977, the 30th World Health Assembly decided that the main social target of governments and WHO in the coming decades should be "the attainment by the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life, for brevity, called "Health for All". With the adoption of health as an integral part of socio-economic development by the United Nations in 1979, health, while being an end in itself, has also become a major instrument of overall socio-economic development and the creation of a new social order.

CHANGING CONCEPTS

An understanding of health is the basis of all health care. Health is not perceived the same way by all members of a community including various professional groups (e.g., biomedical scientists, social science specialists, health administrators, ecologists, etc) giving rise to confusion about the concept of health, in a world of continuous change, new concepts are bound to emerge based on new patterns of thought. Health has evolved over the centuries as a concept from an individual concern to a world-wide social goal and encompasses the whole quality of life. A brief account of the changing concepts of health is given below:

1. Biomedical concept

Traditionally, health has been viewed as an "absence of disease, and if one was free from disease, then the person was considered healthy. This concept, known as the "biomedical concept" has the basis in the "germ theory of disease" which dominated medical thought at the turn of the 20th century. The medical profession viewed the human body as a machine, disease as a consequence of the breakdown of the machine and one of the doctor's task as repair of the machine. Thus health, in this narrow view, became the ultimate goal of medicine.

The criticism that is levelled against the biomedical concept is that it has minimized the role of the environmental, social, psychological and cultural determinants of health. The biomedical model, for alt its spectacular success in treating disease, was found inadequate to solve some of the major health problems of mankind (e.g., malnutrition, chronic diseases, accidents, drug abuse, mental illness, environmental pollution, population explosion) by elaborating the medical technologies. Developments in medical and social sciences led to the conclusion that the biomedical concept of health was inadequate.

2. Ecological concept

Deficiencies in the biomedical concept gave rise to other concepts. The ecologists put forward an attractive hypothesis which viewed health as a dynamic equilibrium between man and his environment, and disease a maladjustment of the human organism to environment. Dubos defined health saying: "Health implies the relative absence of pain and discomfort and a continuous adaptation and adjustment to the environment to ensure optimal function". Human ecological and cultural adaptations do determine not only the occurrence of disease but also the availability of food and the population explosion. The ecological concept raises two issues, viz. imperfect man and imperfect environment. History argues strongly that improvement in human adaptation to natural environments can lead to longer life expectancies and a better quality of life - even in the absence of modern health delivery services.

3. Psychosocial concepts

Contemporary developments in social sciences revealed that health is not only a biomedical phenomenon, but one which is influenced by social, psychological, cultural, economic and political factors of the people concerned. These factors must be taken into consideration in defining and measuring health. Thus health is both a biological and social phenomenon.

4. Holistic concept

The holistic model is a synthesis of all the above concepts. It recognizes the strength of social, economic, political and environmental influences on health. It has been variously described as a unified or multidimensional process involving the well-being of the whole person in the context of his environment. This view corresponds to the view held by the ancients that health implies a sound mind, in a sound body, in a sound family, in sound environment. The holistic approach implies that all sectors of society have an effect on health, in particular, agriculture, animal husbandry, food, industry, education, housing-, public works, communications and other sectors. The emphasis is on the promotion and protection of health.

DEFINITIONS OF HEALTH

"Health" is one of those terms which most people find it difficult to define although they are confident of its meaning. Therefore, many definitions of health have been offered from time to time, including the following:

a. "the condition of being sound in body, mind or spirit, especially freedom from physical disease or pain" (Webster);

b. "soundness, of body or mind; that condition in which its functions are duly and efficiently discharged" (Oxford English Dictionary);

c. "a condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic and environmental";

d. "a modus vivendi enabling imperfect men to achieve a rewarding and not too painful existence while they cope with an imperfect world";

e. "a state of relative equilibrium of body form and function which results from its successful dynamic adjustment to forces tending to disturb it. It is not passive interplay between body substance and forces impinging upon it but an active response of body forces working toward readjustment" (Perkins).

WHO definition

The widely accepted definition of health is that given by the World Health Organization (1948) in the preamble to its constitution, which is as follows:

"Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity"

In recent years, this statement has been amplified to include the ability to lead a "socially and economically productive life".

The WHO definition of health has been criticised as being too broad. Some argue that health cannot be defined as a state at all, but must be seen as a process of continuous adjustment to the changing demands of living and of the changing meanings we give to life. It is a dynamic concept. !t helps people live well work well and enjoy themselves. The WHO definition of health is therefore considered by many as an Idealistic goal than a realistic proposition. It refers to a situation that may exist in some individuals but not in everyone all the time; it is not usually observed m groups of human beings and in communities. Some consider it irrelevant to everyday demands, as nobody qualifies as healthy, i.e., perfect biological, psychological and social functioning. That is, if we accept the WHO definition, we are all sick.

In spite of the above limitations, the concept of health as defined by WHO is broad and positive in its implications; it sets out the standard, the standard of "positive" health. It symbolized the aspirations of people and represents an overall objective or goal towards which nations should strive.

Operational definition of health

The WHO definition of health is not an operational definition, i.e., it does not lend itself to direct measurement Studies of epidemiology of health have been hampered because of our inability to measure health and well-being directly. In this connection an "operational definition" has been devised by a WHO study group. In this definition, the concept of health is viewed as being of two orders. In a broad sense, health can be seen as "a condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic or environmental".

In a narrow sense - one more useful for measuring purposes - health means: (a) there is no obvious evidence of disease, and that a person is functioning normally, i.e., conforming within normal limits of variation to the standards of health criteria generally accepted for one's age, sex, community, and geographic region; and (b) the several organs of the body are functioning adequately in themselves and in relation to one another, which implies a kind of equilibrium or homeostasis a condition relatively stable but which may vary as human beings adapt to internal and external stimuli.

New philosophy of health

In recent years, we have acquired a new philosophy of health, which may be stated as below:

- health is a fundamental human right

- health is the essence of productive life, and not the result of ever increasing expenditure on medical care

- health is intersectoral

- health is an integral part of development

- health is central to the concept of quality of life

- health involves individuals, state and international responsibility

- health and its maintenance is a major social investment

- health is world-wide social goal

 

DIMENSIONS OF HEALTH

Health is multidimensional. The WHO definition envisages three specific dimensions - the physical, the mental and the social. Many more may be cited, viz. spiritual, emotional, vocational and political dimensions. As the knowledge base grows, the list may be expanding. Although these dimensions function and interact with one another, each has its own nature, and for descriptive purposes will be treated separately.

1. Physical Dimension

The physical dimension of health is probably the easiest to understand. The state of physical health implies the notion of "perfect functioning" of the body. It conceptualizes health biologically as a state in which every cell and every organ functioning at optimum capacity and in perfect harmony with the rest of the body. However, the term "optimum" is not definable.

The signs of physical health in an individual are: "a good complexion, a clean skin, bright eyes, lustrous hair with a body well clothed with firm flesh, not too fat, a sweet breath, a good appetite, sound sleep, regular activity of bowels and bladder and smooth, easy, coordinated bodily movements. All the organs of the body are of unexceptional size and function normally: all the special senses are intact; the resting pulse rate, blood pressure and exercise tolerance are all within the range of "normality" for the individual's age and sex. In the young and growing individual there is a steady gain in weight and in the future this weight remains more or less constant at a point about 5 lbs (2.3 kg) more or less than the individual's weight at the age of 25 years. This state of normality has fairly wide limits. These limits are set by observation of a large number of "normal" people, who are free from-evident disease.

Evaluation of physical health:

Modern medicine has evolved tools and techniques which may be used in various combinations for the assessment of physical health. They include:

- self assessment of overall health

- inquiry into symptoms of ill health and risk factors

- inquiry into medications

- inquiry into levels of activity (e.g., number of days of restricted activity within a specified time, degree of fitness)

- inquiry into use of medical services (e.g., the number of visits to a physician, number of hospitalizations) in the recent past

- standardized questionnaires for cardiovascular diseases

- standardized questionnaires for respiratory diseases

- clinical examination

- nutrition and dietary assessment

- biochemical and laboratory investigations

At the community level, the state of health may be assessed by such indicators as death rate, infant mortality rate and expectation of life. Ideally, each piece of information should be individually useful and when combined should permit a more complete health profile of individuals and communities.

2. Mental dimension

Mental health is not mere absence of mental illness. Good mental health is the ability to respond to the many varied experiences of life with flexibility and a sense of purpose. More recently, mental health has been defined as "a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a coexistence between the realities of the self and that of other people and that of the environment".

A few short decades ago, the mind and body were considered independent entities. Recently, however, researchers have discovered that psychological factors can induce all kinds of illness, not simply mental 6nes. They include conditions such as essential hypertension, peptic ulcer and bronchial asthma. Some major mental illnesses such as depression and schizophrenia have a biological component. The underlying Inference is that there is a behavioural, psychological or biological dysfunction and that the disturbance in the mental equilibrium is not merely in the relationship between the individual and society.

Although, mental health is an essential component of health, the scientific foundations of mental health are not yet clear. Therefore we do not have precise tools to assess the state of mental health unlike physical health. Psychologists have mentioned the following characteristics as attributes of a mentally healthy person:

a. a mentally healthy person is free from internal conflicts;

he is not at "war" with himself,

b. he is well-adjusted, i.e., he is able to get along well with others. He accepts criticism and is net easily upset,

c. he searches for identity

d. he has a strong sense of self-esteem

e. he knows himself: his needs, problems and goals-(this is known as self-actualization)

f. he has good self-control-balances rationality and emotionality

g. he faces problems and tries to solve them intelligently, i.e. coping with stress and anxiety.

Assessment of mental health at the population level may be made by administering mental status questionnaires by trained interviewers. The most commonly used questionnaires seek to determine the presence and extent of "organic disease" and of symptoms that could indicate psychiatric disorder; some personal assessment of mental well-being is also made. The most basic decision to be made in, assessing mental health is whether to assess mental functioning, i.e., the extent to which cognitive or affective impairments impede role performance and subjective life quality, or psychiatric diagnosis.

One of the keys to good health is a positive mental health. Unfortunately, our knowledge about mental health is far from complete.

3. Social dimension

Social well-being implies harmony and integration within the individual, between each individual and-other members of society and between individuals and the world in which they live. It has been defined as the "quantity and quality of an individual's interpersonal ties and the extent of involvement with the community".

The social dimension of health includes the levels of social skills one possesses, social functioning and the ability, to see oneself as a member of a larger society. In general, social health takes into account that every individual is part of a family and of wider community and focuses on social and economic conditions and well-being of the "whole person" in the context of his social network. Social health' is rooted in "positive material environment" (focusing on financial and residential matters), and "positive human environment" which is concerned with the social network of the individual.

4. Spiritual dimension

Proponents of holistic health believe that the time has come to give serious consideration to the spiritual dimension and to the role this plays in health and disease. Spiritual health in this context, refers to that part of the individual which reaches out and strives for meaning and purpose in life. It is the intangible "something" that transcends physiology and psychology. As a relatively new concept, it seems to defy concrete definition. It includes integrity, principles and ethics, the purpose in life, commitment to some higher being and belief in concepts that are not subject to "state of the art" explanation.

5. Emotional dimension

Historically the mental and emotional dimensions have been seen as one element or as two closely related elements. However, as more research becomes available a definite difference is emerging. Mental health can be seen as knowing or "cognition" while emotional health relates to "feeling". Experts in psychobiology have been relatively successful in isolating these two separate dimensions. With this new data, the mental and emotional aspects of human ness may .have to be viewed as two separate dimensions of human health.

6. Vocational dimension

The vocational aspect of life is a new dimension. It is part of human existence. When work is fully adapted to human goals, capacities and limitations, work often plays a role in promoting both physical and mental health. Physical work is usually associated with an improvement in physical capacity, while goal achievement and self-realization in work are a source of satisfaction and enhanced self-esteem.

The importance of this dimension is exposed when individuals suddenly lose their jobs or faced with mandatory retirement. For many individuals, the vocational dimension may be merely a source of income. To others, this dimension represents the -culmination of the efforts of other dimensions as they function together to produce what the individual considers life "success".

7. Others

A few other dimensions have also been suggested such as:

- philosophical dimension

- cultural dimension

- socioeconomic dimension

- environmental dimension

- educational dimension

- nutritional dimension

- curative dimension

- preventive dimension

A glance at the above dimensions shows that there are many "non-medical" dimensions of health, e.g., social, cultural, educational, etc. These symbolize a huge range of factors to which other sectors besides health must contribute if all people are indeed to attain a level of health that will permit them to lead a socially and economically productive life.

HEALTH - A RELATIVE CONCEPT

An alternative approach to positive health conceptualizes health not as an ideal state, but as a biologically "normal" state, based on statistical averages. For example, a newborn baby in India weighs 2,8 kg on an average compared to 3.5 kg in the developed countries, and yet compares favourably in health. The height and weight standards vary from country to country and also between socio-economic groups. Many normal people show heart murmurs, enlarged tonsils and X-ray shadows in the chest and yet do not show signs of illhealth. Thus health is a relative concept and health standards vary among cultures social classes and age-groups. This implies that health in any society should be defined in terms of prevailing ecological conditions. That is, instead of setting universal health standards, each country will decide on its own norms for a given set of prevailing conditions and then look into ways to achieve that level.

CONCEPT OF WELLBEING

The WHO definition of health introduces the concept of "well-being". The question then arises: what is meant by wellbeing? In point of fact, there is no satisfactory definition of the term wellbeing.

Recently, psychologists have pointed out that the wellbeing of an individual or group of individuals have objective and subjective components. The objective components relate to such concerns as are generally known by the term "standard of living" or "level of living". The subjective component of well-being (as expressed by each individual) is referred to as quality of life. Let us consider these concepts separately.

1. Standard of living

The term "standard of living" refers to the usual scale of our expenditure, the goods we consume and the services we enjoy. It includes the level of education, employment status, dress, house, amusements and comforts of modern living.

A similar definition, corresponding to the above, was proposed by WHO: "Income and occupation, standards of housing, sanitation and nutrition, the level of provision of health, educational, recreational and other services may all be used individually as measures of socio-economic status, and collectively as an index of the "standard of living".

There are vast inequalities in the standards of living of the people in different countries of the world. The extent of these differences are usually measured through the comparison of per capita GNP on which the standard of living primarily depends.

2. Level of living

The parallel term for standard of living used in United Nations documents is "level of living". It consists of nine components: health, food consumption, education, occupation and working conditions, housing, social security, clothing, recreation and leisure and human rights. These objective characteristics are believed to influence human wellbeing. It is considered that health is the most important component of the level of living because its impairment always means impairment of the level of living.

3. Quality of life

Much has been said and written on the quality of life in recent years. It is the "subjective" component of wellbeing. "Quality of life" was defined by WHO as: "the condition of life resulting .from the combination of the effects of the complete range of factors such .as those determining health, happiness (including comfort in the physical environment and a satisfying occupation), education, social and intellectual attainments, freedom of action, justice and freedom of expression".

A recent definition of quality of life is as follows: "a composite measure of physical, mental and social wellbeing as perceived by each individual or by group of individuals - that is to say, happiness, satisfaction and gratification as it is experienced in such life concerns as health, marriage, family work, financial situation, educational opportunities, self-esteem, creativity, belongingness, and trust in others".

Thus, a distinction is drawn between the concept of "level of living" consisting of objective criteria and of "quality of life" comprising the individual's own subjective evaluation of these. The quality of life can be evaluated by assessing a person's subjective, feelings of happiness or unhappiness about the various life concerns.

People are now demanding a better quality of life. Therefore, governments all over the world are increasingly concerned about improving the quality of life of their people by reducing morbidity and mortality, providing primary health care and enhancing physical, mental and social well-being. It is conceded that a rise in the standard of living of the people is not enough to achieve satisfaction or happiness. Improvement of quality of life must also be added, and this means increased emphasis on social policy and on reformulation of societal goals to make life more livable for all those who survive.

Physical quality of life index

As things stand at present, this important concept of quality of life is difficult to define and even more difficult to measure. Various attempts have been made to reach one composite index from a number of health indicators. The "Physical quality of life index" is one such index. It consolidates three indicators, viz. infant mortality, life expectancy at age one, and literacy. These three components measure the results rather than inputs. As such they lend themselves to international and national comparison.

For each component, the performance of individual countries is placed on a scale of 0 to 100, where 0 represents an absolutely defined "worst" performance, and 100 represents an absolutely defined "best" performance. The composite index is calculated by averaging the three indicators, giving equal weight to each of them. The resulting PQLI thus also is scaled 0 to 100.

It may be mentioned that PQLI has not taken per capita GNP into consideration, showing thereby that "money is not everything". For example, the oil-rich countries of Middle East with high per capita incomes have in fact not very high PQLIs. At the other extreme, Sri Lanka and Kerala state in India have low per capita incomes with high PQLIs. In short, PQLI does not measure economic growth; it measures the results of social, economic and political policies. It is intended to complement, not replace GNP. The ultimate objective is to attain a PQLI of 100.

Human Development Index

Human development index (HDI) is defined as "a composite index combining indicators representing three dimensions -longevity (life expectancy at birth); knowledge (adult literacy rate and mean years of schooling); and income (real GDP per capita in purchasing power - parity dollars)".

Thus the concept of HDI reflects achievements in .the most basic human capabilities, viz., leading a long life, being knowledgeable and enjoying a decent standard of living. Hence, three variables has been chosen to represent those dimensions. The HDI is a more comprehensive measure than per capita income. Income is 'only a means to human development, not an end. Nor is it, a sum total of human lives. Thus by focusing on areas beyond income and treating income as a proxy for a decent standard of living, the HDI provides a more comprehensive picture of human life than income does.

The HDI values ranges between 0 to 1. The HDI value for a country shows the distance that it has already traveled towards maximum possible value to 1, and also allows comparisons with other countries.

To construct the index, fixed minimum and maximum values have been established for each of these indicators, (say x1).

- Life expectancy at birth: 25 years and 85 years

- Adult literacy rate: 0 per cent and 100 per cent

- Combined gross enrolment ratio: 0 per cent and 100 per cent

- Real GDP per capita (PPP$): $ 100 and $ 40,000 (PPP $)

For any component of the HDI, individual indices can be computed according the general, formula:

Index

=

(Actual x1 Value) - {Minimum x1 Value)

(Maximum x1 Value) - (Minimum x1 Value)

The construction of HDI methodology can be illustrated with the example of India for the year 1999.

The life expectancy at birth for India is 62.6 years, then the life expectancy index will be:

Life expectancy index = = = 0,626

The adult literacy rate of India is 53.5 per cent.

Adult literacy index = = = 0,535

The combined gross enrolment ratio for India is 55 per cent.

55

100

Combined gross enrolment index = = = 0,55

Educational attainment is measured by a combination of adult literacy (two - thirds weight) and combined primary, secondary and tertiary enrolment ratio (one - third weight). Hence education attainment for India will be:

= 0,54

As the real GDP per capita (PPP$) for India is 1670, then adjusted real GDP per capita (PPP$) index will be:

log (1670)-log (100)

=

0,47

log (40,000)-log (100)

Human Development Index is a simple average of above three indices, i.e.

HDI for India is 0,626 + 0,54 + 0,47 = 1,636/3 = 0,545

of the 174 countries for which HDI has been constructed for the year 1999, 45 are in the high human development category with, an HDI value equal to or more than 0.800); 94 are in the medium human development category (0.500 - 0.799), and 35 in the low human development category (less than 0.500). Canada, Norway and USA are at the top of HDI ranking and Sierra Leone, Niger and Ethiopia at the bottom. India comes in the medium human development category, ranking at no. 132.

Disparities between regions can be significant with some regions having more ground to cover in making the shortfall than others. The link between the economic prosperity and human, development is neither automatic nor obvious. Two countries with similar income per capita can have very different HDI values and countries having similar HDI can have very different income levels.

The concept of Gender - Related Development index (GDI) and Gender Empowerment Measure (GEM) were introduced during the year 1995. These terms are composite measures reflecting gender inequalities in human development. While GDI reflects achievements in. the basic human development adjusted for gender inequalities, GEM measures gender inequalities in economic and political opportunities. During the year 1997 another term Human Poverty Index (HPI) was introduced while the HDI measures average achievements in basic dimensions of human development, the HPI measures deprivation in those dimensions.

SPECTRUM OF HEALTH

Health and disease lie along a continuum, and there is no single cut-off point. The lowest point on the health-disease spectrum is death and the highest point corresponds to the WHO definition of positive health (Fig.2). It is thus obvious that health fluctuates within a range of optimum well-being to various levels of dysfunction, including the state of total dysfunction, namely the death. The transition from optimum health to illhealth is often gradual, and where one state ends and the other beams is a matter of judgment.

The spectral concept of health emphasizes that the health of any individual is not static; it is a dynamic phenomenon and a process of continuous change, subject to frequent subtle variations. What is considered maximum health today may be minimum tomorrow? That is, a person may function at maximum levels of health today, and diminished levels of health tomorrow. It implies that health is a state not to be attained once and for all, but ever to be renewed. There are degrees or "levels of health" as there are degrees or severity of illness. As long as we are alive there is some degree of health in us.

Positive health

Better health

Freedom from sickness

 

Unrecognised sickness

Mild sickness

Severe sickness

Death

FIG. 2. The Health Sickness Spectrum

DETERMINANTS OF HEALTH

Health is multifactorial. The factors which influence health lie both within the individual and externally in the society in which he or she lives. It is a truism to say that what man is and to what diseases he may fall victim depends on a .combination of two sets of factors - his genetic factors and the environmental factors to which he is exposed. These factors interact and these interactions may be health-promoting or deleterious. Thus, conceptually, the health of individuals and whole communities may be considered to be the result of many interactions. Only a brief indication of the more important determinants or variables are shown in fig. 3.

1. Biological determinants


The physical and mental traits of every human being are to some extent determined by the nature of his genes at the moment of conception. The genetic make-up is unique in that it cannot be altered after conception. A number of diseases are now known to be of genetic origin, e.g., chromosomal anomalies, errors of metabolism, mental retardation, some types of diabetes, etc. The state of health therefore depends partly on the genetic constitution of man. Nowadays, medical genetics offers hope for prevention and treatment of a wide spectrum of diseases, thus the prospect of better medicine and longer healthier life. A vast field

 

Fig. 3. Determinants of health

 

of knowledge has yet to be exploited. It plays a particularly important role in genetic screening and gene therapy.

Thus, from the genetic stand-point, health may be defined as that "state of the individual which is based upon the absence from the genetic constitution of such genes as correspond to characters that take the form of serious defect and derangement and to the absence of any aberration in respect of the total amount of chromosome material in the karyotype or stated in positive terms, from the presence in the genetic constitution of the genes that correspond to the normal characterization and to the presence of a normal karyotype".

The "positive health" advocated by WHO implies that a person should be able to express as completely as possible the potentialities of his genetic heritage. This is possible only when the person is allowed to live in healthy relationship with his environment - an environment that transforms genetic potentialities into phenotypic realities.

2. Behavioral and socio-cultural conditions

The term "lifestyle" is rather a diffuse concept often used to denote "the way people live", reflecting a whole range of social values, attitudes and activities. It is composed of cultural and behavioral patterns and lifelong personal habits (e.g., sticking, alcoholism) that have developed through processes of socialization. Lifestyles are learnt through social interaction with parents, peer groups, friends and siblings and through school and mass media.

Health requires the promotion of healthy lifestyle. In the last 20 years, a considerable body of evidence has accumulated which indicates that there is an association between health and lifestyle of individuals. Many current-day health problems especially in the developed countries (e.g., coronary heart disease, obesity, lung cancer, drug addiction) are associated with lifestyle changes. In developing countries such as India where traditional lifestyles still persist, risks of illness and death are connected with lack of sanitation, poor nutrition, personal hygiene, elementary human habits, customs and cultural patterns.

It may be noted that not all lifestyle factors are harmful. There are many that can actually promote health. Examples include adequate nutrition, enough sleep, sufficient physical activity, etc. In short, the achievement of optimum health demands adoption of healthy lifestyles. Health is both a consequence of an individual's lifestyle and a factor in determining it.

3. Environment

It was Hippocrates who first related disease to environment, e.g., climate, water, air, etc. Centuries later, Pettenkofer in Germany revived the concept of disease-environment association.

Environment is classified as "internal" and "external". The Internal environment of man pertains to "each and every component part, every tissue, organ and organ-system and their harmonious functioning within the system". Internal environment is the domain of internal medicine. The external or macro-environment consists of those things to which man is exposed after conception. It is defined as "all that which is external to the individual human host. It can be divided into physical, biological and psychosocial components, any or all of which can affect the health of man and his susceptibility to illness. Some epidemiologists have used the term "microenvironment" (or domestic environment) to personal environment which includes the individual's way of living and lifestyle, e.g., eating habits, other personal habits (e.g., smoking or drinking), use of drugs, etc. It is also customary to speak about occupational environment, socioeconomic environment and moral environment.

It is an established fact that environment has a direct impact on the physical, mental and social well-being of those living in it. The environmental factors range from housing, water supply, psychosocial stress and family structure through social and economic support systems, to the organization of health and social welfare services in the community.

The environmental components (physical, biological and. psychological) are not water-tight compartments. They are so inextricably linked with one another that it is realistic and fruitful to view the human environment in toto when we consider the influence of environment on the health status of the population. If the environment is favorable to the individual, he can make full use of his physical and mental capabilities. Protection and promotion of family and environmental health is one of the major issues in the world today.

4. Socio-economic conditions

Socioeconomic conditions have long been known to influence human health. For the majority of the world's people, health status is determined primarily by their level of socioeconomic development, e.g., per capita GNP, education, nutrition, employment, housing, the political system of the country, etc. Those of major importance are:

(I)               Economic status: The per capita GNP is the most widely accepted measure of general economic performance. There can be no doubt that in many developing countries, .it is the economic progress that has been the major factor in reducing morbidity, increasing life expectancy and improving the quality of life (Table 3). The economic status determines the purchasing power, standard of living, quality .of life, family size and the pattern of disease and deviant behavior in the community. It is also an important factor in seeking health care. Ironically, affluence may also be a contributory cause of illness as exemplified by the high rates of coronary heart disease, diabetes and obesity in the upper socioeconomic groups.

(II) Education: A second major factor influencing health status is education (especially female education). The world map of illiteracy closely coincides with the maps of poverty, malnutrition, illhealth, high infant and child mortality rates. Studies indicate that education, to some extent, compensates the effects of poverty on health, irrespective of the availability of health facilities. The small state of Kerala in India Is a striking example. Kerala has an estimated infant mortality rate of 14 compared to 71 for all-India in 1999. A major factor in the low infant mortality of Kerala is its highest female literacy rate of 87.86 per cent compared to 54.16 per cent for all-India.

(III) Occupation: The very state of being employed in productive work promotes health, because the unemployed usually show a higher incidence of illhealth and death. For many, loss of work may mean loss of income, and status. It can cause psychological and social damage.

(IV) Political system: Health is also related to the country's political system. Often the main obstacles to the implementation of health technologies are not technical, but rather political. Decisions concerning resource allocation, manpower policy, choice of technology and the degree to which health services are made available and accessible to different segments of the society are example's of the manner in which the political system can shape community, health services. The percentage of GNP spent on health is a quantitative indicator of political commitment. Available information shows that India spends about 3 per cent of its GNP on health and family welfare. To achieve the goal of health for alt, WHO has set the target of at least 5 per cent expenditure of each country's GNP on health care. What is needed is political commitment and leadership which is oriented towards social development, and not merely economic development. If poor health patterns are to be changed, then changes must be made in the entire sociopolitical system in any given community. Social, economic and political actions are required to eliminate health hazards in people's working and living environments.

5. Health services

The term health and family welfare services cover a wide spectrum of personal and community services for treatment of disease, prevention of illness and promotion of health. The purpose of health services' is to improve the health status of population. For example, immunization of children can influence the incidence/prevalence of particular diseases. Provision of safe water can prevent mortality and morbidity from water-borne diseases. The care of pregnant women and children would contribute to the reduction of maternal and child morbidity and mortality. To be effective, the health services must reach the -social periphery, equitably distributed, accessible at a cost the country and community can afford and socially acceptable. All these are ingredients of what is now termed "primary health care", which is seen as the way to better health.

Health services can also be seen as essential for social and economic development. It is well to remind ourselves that health care does not produce good health. Whereas, there is a strong correlation between GNP and expectation of life at birth, there is no significant correlation between medical density and expectation of life at birth. The most we can expect from an effective health service is good care. The epidemiological perspective emphasizes that health services, no matter how technically elegant or cost-effective, are ultimately pertinent only if they improve health.

6. Aging of the Population

By the year 2020, the world will have more than one billion people aged 60 and over and more than two thirds of them living in developing countries. Although the elderly in many countries enjoy better health than hitherto, a major concern of rapid population aging is the increased prevalence of chronic diseases and disabilities both being conditions that tend to accompany the aging process and deserve special attention.

7. Gender

The 1990s have witnessed an increased concentration on women's issues. In 1993, the Global Commission on Women's Health was established. The commission drew up an agenda for action on women's health covering nutrition, reproductive health, the health consequences of violence, aging, lifestyle related-conditions and the occupational environment. It has brought about an increased awareness among policy - makers of women's health issues and encourages their inclusion in all development plans as a priority.

8. Other factors

We are witnessing the transition from post industrial age to an information age and experiencing the early days of two interconnected revolutions, in information and in communication. The development of these technologies offers tremendous opportunities in providing an easy and instant access to medical information once difficult to retrieve. It contributes to dissemination of information worldwide, serving the needs of many physicians, health professionals, biomedical scientists and researchers, the mass media and the public.

Other contributions to the health of population derive from systems outside the formal health care system, i.e., health related systems (e.g., food and agriculture, education, industry, social welfare, rural development) as well as adoption of these in the economic and social fields that would assist in raising the standards of living. This would include employment opportunities, increased wages, prepaid medical programmes and family support systems.

In short, medicine is not the sole contributor to the health and wellbeing of population. The potential of intersectoral contributions to the health of communities is increasingly recognized.

RESPONSIBILITY FOR HEALTH

Health is on one hand a highly personal responsibility and on the other hand a major public concern. It thus involves the joint efforts of the whole social fabric, viz. the individual, the community and the state to protect and promote health.

1. Individual responsibility

Although health is now recognized a fundamental human right, it is essentially an individual responsibility. It is not a commodity that one Individual can bestow on another. No community or state programme of health services can give health. In large measure, it has to be earned and maintained by the individual himself, who must accept a broad spectrum of responsibilities, now known as "self care".

Self care in health

A recent trend in health care is self care. It is defined as "those health-generating activities that are undertaken by the persons themselves". It refers to those activities individuals undertake in promoting their own health, preventing their own disease, limiting their .own illness, and restoring their own health. These activities are undertaken without professional assistance, although individuals are informed by technical knowledge and skills. The generic attribute of self care is its non-professional, non-bureaucratic, non-industrial character; its natural place in social life.

Self care activities comprise observance of simple rules of behavior relating to diet, sleep, exercise, weight, alcohol, smoking and drugs. Others include attention to personal hygiene, cultivation of healthful habits and lifestyle, submitting oneself to selective medical examinations and screening; accepting immunization and carrying out other specific disease prevention measures, reporting early when sick and accepting treatment, undertaking measures for the prevention of a relapse or of the spread of the disease to others. To these must be added family planning which is essentially an individual responsibility.

The shift in disease patterns from acute to chronic disease makes self-care both a logical necessity and an appropriate strategy. For example, by teaching patients self-care (e.g., recording one's own blood pressure, examination of urine for sugar), the burden on the official health services would be considerably reduced. In other words, health must begin with the individual.

2. Community responsibility

Health can never be adequately protected by health services without the active understanding and involvement of communities whose health is at stake. Until quite recently, throughout the world, people were neglected as a health 'resource; they were merely looked upon as sources of pathology or victims of pathology and consequently as a "target" for preventive and therapeutic services. This negative view of people's role in health has changed because of the realization that there are many things which the individual cannot do for himself except through united community effort. The individual and community responsibility are complementary, not antithetical. The current trend is to "demedicalize" health and involve the communities in a meaningful way. This implies a more active involvement of families and communities in health matters, viz. planning, implementation, utilization, operation and evaluation of health services. In other words, the emphasis has shifted from health care for the people to health care by the people. The concept of primary health care centres round people's participation in their own activities. The Village Health Guides' scheme in India, launched in 1977, is an example of community participation.

There are three ways in which a community can participate: (I) the community can provide in the shape of facilities, manpower, logistic support, and possibly funds (II) it also means the community can be actively involved in planning, management, and evaluation, and (III) an equally important contribution that people can make is by joining in and using the health services. This is particularly true of preventive and protective measures. Further, no standard pattern of community participation can be recommended since there is a wide range of economic and social problems, as well as political and cultural traits among and within the communities. What is essential is flexibility of approach.

However, community involvement is not easy to obtain as extensive experience has indicated. The traditional Indian society is cut across on rigid religion and caste lines, and appropriate role for each caste group has been a serious obstacle in securing complete community participation. And in the health sector, the greatest resistance to health guides' involvement in primary health care came from the medical profession than the lay public. Community participation has become an aphorism that is still awaiting genuine realization in many countries of the world.

Long ago, Henry Sigerist, the medical historian stated that "The people's health ought to be the concern of the people themselves. They must struggle for it and plan for it. The war against disease and for health cannot be fought by physician alone. It is a people's war in which the entire population must be mobilised permanently".

3. State responsibility

The responsibility for health does not end with the individual and community effort. In all civilized societies, the State assumes responsibility for the health and welfare of its citizens. The Constitution of India provides that health is a State responsibility. The relevant portions are to be found In the Directive Principles of State Policy, .which are as below:

The State shall, in particular, direct the policy towards securing -

....that the health and strength of workers, men and women and the tender age of children are not abused and that citizens are not forced by economic necessity to enter avocations unsuited to their age or strength.

....that childhood and youth are protected against exploitation and against moral and material abandonment.

The State shall, within the limits of its economic capacity and development, make effective provision for securing the right to work, to education and to public assistance in cases of unemployment, old age, sickness and disablement, and in other cases of undeserved want.

The State shall make provision for securing just and humane conditions of work and maternity relief.

The State shall regard the raising of the level of nutrition and standard of living of its people and the improvement of public health as among its primary duties.

4. International responsibility

The health of mankind requires the cooperation of governments, the people, national and international organizations both within and outside the United Nations system in achieving our health goals. This cooperation covers such subjects as exchange of experts, provision of drugs and supplies, border meetings with regard to control of communicable diseases and achievement of "Health for All" through primary health care. The TCDC (Technical Cooperation in Developing Countries), ASEAN (Association of South-east Asian Nations) and the recently established SAARC (South Asia Association for Regional Cooperation) are important regional mechanisms for such cooperation.

The eradication of smallpox, the pursuit of "Health for All" and the campaign against smoking and AIDS are a few recent examples of international responsibility for the control of disease and promotion of health. Today, 'more than ever before, there is a wider International understanding on matters relating to health and "social Injustices" in the distribution of health services. The WHO is a major factor in fostering international cooperation in health. In keeping with its constitutional mandate, WHO acts as a directing and coordinating authority on international health work.

INDICATORS OF HEALTH

A question that is often raised is: How healthy is a given community? Indicators are required not only to 'measure, the health status of a community, but also to compare the health status of one country with that of another; for assessment of health care needs; for allocation of scarce resources; and for monitoring and evaluation of health services, activities and programmes. Indicators help to measure the extent to which the objectives and targets of a programme are being attained.

As the name suggests, indicators are only an indication of a given situation or a reflection of that situation. In WHO's guidelines for health programme evaluation they are defined as variables which help to measure changes. Often they are used particularly when these changes cannot be measured directly, as for example health or nutritional status. If measured sequentially over time, they can indicate direction and speed of change and serve to compare different areas or groups of people at the same moment in time.

There has been some confusion over terminology: health indicator as compared to health index (plural: indices or indexes). It has been suggested that in relation to health trends, the term indicator is to be preferred to index, whereas health index is generally considered to be an amalgamation of health indicators.

Characteristics of indicators:

Indicators have been given scientific respectability; for example ideal indicators

a. should be valid, i.e., they should actually measure what they are supposed to measure;

b. should be reliable and objective, i.e., the answers should be the same if measured by different people in similar circumstances;

c. should be sensitive, i.e., they should be sensitive to changes in the situation concerned,

d. should be specific, i.e., they should reflect changes only in the situation concerned,

e. should be feasible, i.e., they should have the ability to obtain data needed, and;

j. should be relevant, i.e., they should contribute to the understanding of the phenomenon of interest.

But in real life there are few indicators that comply with all these, criteria. Measurement of health is far from simple. No existing definition (including the WHO definition) contains criteria for measuring health. This is because health, like happiness, cannot be defined in exact measurable terms. Its presence or absence is so largely a matter of subjective judgement. Since we have problems in defining health, we also have problems in measuring health and the question is largely unresolved. Therefore, measurements of health have been framed in terms of illness (or lack of health), the consequences of illhealth (e.g., morbidity, disability) and economic, occupational and domestic factors that promote illhealth - all the antitheses of health.

Further, health is multidimensional, and each dimension is influenced by numerous factors, some known and many unknown. This means we must measure health multidimensionally. Thus the subject of health measurement is a complicated one even for professionals. Our understanding of health therefore cannot be in terms of a single indicator; it must be conceived in terms of a profile, employing many indicators, which may be classified as:

1. Mortality indicators

2. Morbidity indicators

3. Disability rates

4. Nutritional status indicators

5. Health care delivery indicators

6. Utilization rates

7. Indicators of social and mental health

8. Environmental indicators

9. Socio-economic indicators

10. Health policy indicators

11. Indicators of quality of life

12. Other indicators

1. Mortality indicators

(a) Crude death rate: This is considered a fair Indicator of the comparative health of the people. It is defined as the number of deaths per 1000 population per year in a given community. It indicates the rate at which people are dying. Strictly speaking, health should not be measured by the number of deaths that occur in a community. But in many countries, the crude death rate is the only available indicator of health. When used for international comparison, the usefulness of the crude death rate is restricted because it is influenced by the age-sex composition of the population. Although not a perfect measure of health status, a decrease in death rate provides a good tool for assessing the overall health improvement in a population. Reducing the number of deaths in the population is an obvious goal of medicine and health care, and success or failure to do so is a measure of a nation's commitment to better health.

(b) Expectation of life: Life expectancy at birth is "the average number of years that will be lived by those born alive into a population if the current age-specific mortality rates persist". Life expectancy at birth is highly influenced by the infant mortality rate where that is high. Life expectancy at the age of 1 excludes the influence of infant mortality, and life expectancy at the age of 5 excludes the influence of child mortality. Life expectancy at birth is used most frequently. It is estimated for both sexes separately. An increase in the expectation of life is regarded, inferentially, as an improvement in health status.

Life expectancy is a good indicator of socioeconomic development in general. As an indicator of long-term survival, it can be considered as a positive health indicator. It has been. adopted as a global health indicator. A minimum life expectancy at birth of 60 years is the goal of Health for All by 2000 AD.

(c) Infant mortality rate: Infant mortality rate is the ratio of deaths under 1 year of age in a given year to the total number of live births in the same year; usually expressed as a rate per 1000 live births. It is one of the most universally accepted indicators of health status not only of infants, but also of whole population and of the socioeconomic conditions under which they live. In addition, the infant mortality rate is a sensitive indicator of the availability, utilization and effectiveness of health care, particularly perinatal care. The global strategy of Health for All has suggested an infant mortality rate of not more than 50 per 1000 live births by 2000 AD.

(d) Child mortality rate: Another indicator related to the overall health status is the early childhood (1 - 4 years) mortality rate. It is defined as the number of deaths at ages 1 - 4 years in a given year, per 1000 children in that age group at the mid-point of the year concerned. It thus excludes infant mortality.

Apart from its correlation with inadequate MCH services, it is also related to insufficient nutrition, low coverage by immunization and adverse environmental exposure and other exogenous agents. Whereas the IMR may be more than 10 times higher in the least developed countries than in the developed countries, the child mortality rate may be as much as 250 times higher. This indicates the magnitude of the gap and the room for improvement.

(e) Under-5 proportionate mortality rate: It is the proportion of total deaths occurring in the under-5 age group. This rate can be used to reflect both infant and child mortality rates. In communities with poor hygiene, the proportion may exceed 60 per cent. In some European countries, the proportion is less than 2 per cent. High rate reflects high birth rates, high child mortality rates and shorter life expectancy.

(f) Maternal (puerperal) mortality rate: Maternal (puerperal) mortality accounts for the greatest proportion of deaths among women of reproductive age in most of the developing world, although its importance is not always evident from official statistics. There are enormous variations in maternal mortality rate according to countrys level of socioeconomic status.

(g) Disease-specific mortality: Mortality rates can be computed for specific diseases. As countries begin to extricate themselves from the burden of communicable diseases, a number of other indicators such as deaths from cancer, cardiovascular diseases, accidents, diabetes, etc have emerged as measures of specific disease problems.

(h) Proportional mortality rate: The simplest measures of estimating the burden of a disease in the community is proportional mortality rate, i.e., the proportion of all deaths currently attributed to it. For example, coronary heart disease is the cause of 25 to 30 per cent of all deaths in most western countries. The proportional mortality rate from communicable diseases has been suggested as a useful health status indicator; it indicates the magnitude of preventable mortality.

Mortality indicators represent the traditional measures of health status. Even today they are probably the most often used indirect indicators of health. As infectious diseases have, been brought under control, mortality rates have declined to very low levels in many countries. Consequently mortality indicators are losing their sensitivity as health indicators in developed countries. However, mortality indicators continue to be used as the starting point in health status evaluation.

2. Morbidity Indicators

To describe health in terms of mortality rates only is misleading. This is because mortality indicators do not reveal the burden-of illhealth in a community, as for example mental illness and rheumatoid arthritis. Therefore morbidity indicators are used to supplement mortality data to describe the health status of a population. Morbidity statistics have also their own drawback; they tend to overlook a large number of conditions which are subclinical or inapparent, that is, the hidden part of the iceberg of disease.

The following morbidity rates are used for assessing illhealth in the community.

a. incidence and prevalence

b. notification rates

c. attendance rates at out-patient departments, health centres, etc.

d. admission, readmission and discharge rates

e. duration of stay in hospital and

f. spells of sickness or absence from work or school.

3. Disability rates

Since death rates have not changed markedly in recent years despite massive health expenditures, disability rates related to illness and injury have come into use to supplement mortality and morbidity indicators. The disability rates are based on the premise or notion that health implies a full range of daily activities. The commonly used disability rates fall into two groups: (a) Event-type indicators and {b) person-type indicators.

(a) Event-type indicators:

I) Number of days of restricted activity

II) Bed disability days

III) Work-loss days (or school loss days) within a specific period

(b) Person-type indicators:

I) Limitation of mobility: For example, confined to bed, confined to the house, special aid in getting around either inside or outside the house.

II) Limitation of active: For example, limitation perform the basic activities of daily living (ADL) -e.g., eating, washing, dressing, going to toilet, moving about, etc; limitation in major activity, e.g., ability to work at a job, ability to housework, etc.

Sullivan's index: This index (expectation of life free of disability) is computed by subtracting from the life expectancy the probable duration of bed disability and inability to perform major activities, according to cross-sectional data from the population surveys. For example, the expectation of life at birth for all persons in the USA in 1965 was 70.2 years, and the approximate expectation of life free of disability worked out to be 64.9 years. Sullivan's index is considered one of the most advanced indicators currently available.

HALE (Health - Adjusted Life Expectancy); The name of the indicator used to measure healthy life expectancy has been changed from disability - adjusted life expectancy (DALE) to health - adjusted life expectancy (HALE). HALE is based on life expectancy at birth but includes an adjustment for time spent in poor health. It is most easily understood as the equivalent number of years in full health that a newborn can expect to live based on current rates of ill - health and mortality.

DALY (Disability - Adjusted Life Year): DALY is a measure of the burden of disease in a defined population and the effectiveness of the interventions. DALYs express years of life lost to premature death and years lived with disability adjusted for the severity of the disability. One DALY is "one lost year of healthy life".

A "premature" death is defined as one that occurs before the age to which a dying person could have expected to survive if he or she was a member of a standardized model population with a life expectancy at birth equal to that of the world's longest - surviving population, Japan. Disease burden is, in effect, the gap between a population's actual health status and some reference status. DALYs are advocated as an alternative to QALYs and claimed to be a valid indicator of health. However, their use as currently expressed and calculated may be limited because necessary data are not available or do not exist. Moreover, the concept postulates a continuum from disease to disability to death that is not universally accepted, particulary by the community of persons with disabilities.

4. Nutritional status indicators

Nutritional status is a positive health indicator. Three nutritional status indicators are considered important as indicators of health status. They are:

a. anthropomctric measurements of preschool children, e.g., weight and height, mid-arm circumference;

b. heights (and sometimes weights) of children al school entry; and

c. prevalence of low birth weight (less than 2.5 kg).

5. Health care delivery indicators

The frequently used indicators of health care delivery are:

a. Doctor-population ratio

b. Doctor-nurse ratio

c. Population-bed ratio

d. Population per health/subcentre

e. Population per traditional birth attendant

These indicators reflect the equity of distribution of health resources in different parts of the country, and of the provision of health care.

6. Utilisation rates

In order to obtain additional information on health status, the extent of use of health services is often investigated. Utilization of services - or actual coverage - is expressed as the proportion of people in need of a service who actually receive it in a given period, usually a year. It is argued that utilization rates give some indication of the care needed by a population, and therefore, the health status of the population. In other words, a relationship exists between utilization of health care services arid health needs and status. Health care utilization is also affected by factors such as availability and accessibility of health services and the attitude of an individual towards his health and the health care system. A few examples of utilization rates are cited below:

a. proportion of infants who are "fully immunized" against the 6 EPI diseases .

b. proportion of pregnant women who receive antenatal care, or have their deliveries supervised by a trained birth attendant.

c. percentage of the population using the various methods of family planning.

d. bed-occupancy rate (i.e., average daily in-patient census/average number of beds).

e. average length of stay (i.e., days of care rendered/discharges).

f. bed turn-over ratio (i.e., discharges/average beds).

The above list is neither exhaustive nor all-inclusive. The list can be expanded depending upon the services provided. These indicators direct attention away from the biological aspects of disease in a population towards the discharge of social responsibility for the organization in delivery of health care services.

7. Indicators of social and mental health

As long as valid positive indicators of social and mental health are scarce, it is necessary to use indirect measures, viz. indicators of social and mental pathology. These include suicide, homicide, other acts of violence and other crime; road traffic accidents, juvenile delinquency; alcohol and drug abuse; smoking; consumption of tranquillizers; obesity, etc. To these may be added family violence, battered-baby and battered-wife syndromes and neglected and abandoned youth in the neighbourhood. These social indicators provide a guide to social action for improving the health of the people.

8. Environmental indicators

Environmental indicators reflect the quality of physical and biological environment in which diseases occur and in which the people live. They include indicators relating to pollution of air and water, radiation, solid wastes, noise, exposure to toxic substances in food or drink. Among these, the most useful indicators are those measuring the proportion of population having access to safe water and sanitation facilities, as for example, percentage of households with safe water in the home or within 15 minutes walking distance from a water standpoint or protected well; adequate sanitary facilities in the home or immediate vicinity.

9. Socioeconomic indicators

These indicators do not directly measure health. Nevertheless, they are of great importance in the interpretation of the indicators of health care. These include:

a. rate of population increase

b. per capita GNP

c. level of unemployment

d. dependency ratio

e. literacy-rates, especially female literacy rates

f. family size

g. housing; the number of persons per room

h. per capita "calorie" availability

10. Health policy indicators

The single most important indicator of political commitment is "allocation of adequate resources". The relevant indicators are: (I) proportion of GNP spent on health services (II) proportion of GNP spent on health-related activities (including water supply and sanitation, housing and nutrition, community development) and (III) proportion of total health resources devoted to primary health care.

11. Indicators of quality of life

Increasingly, mortality and morbidity data have been questioned as to whether they fully reflect the health status of a population. The previous emphasis on using increased life expectancy as an indicator of health is no longer considered adequate, especially in developed countries, and attention has shifted more toward concern about the quality of life enjoyed by individuals and communities. Quality of life is difficult to define and even more difficult to measure (see page 14). Various attempts have been made to reach one composite index from a number of health indicators. The physical quality of life index is one such index (see page 15). It consolidates three indicators, viz. infant mortality, life expectancy at age one, and literacy. Obviously more work is needed to develop indicators of quality of life.

12. Other indicators series

(a) Social indicators: Social indicators, as defined by the United Nations Statistical Office, have been divided into 12 categories: population; family formation, families and households; learning and educational services; earning activities; distribution of income, consumption, and: accumulation; social security and welfare services; health services and nutrition; housing and its environment; public order and safety; time use; leisure and culture, social stratification and mobility.

(b) Basic needs indicators': Basic needs indicators are used by ILO. Those mentioned in "Basic needs performance" include calorie consumption; access to water; life expectancy; deaths due to disease: illiteracy, doctors and nurses per population; rooms per person GNP per capita.

(c) Health for All indicators. For monitoring progress towards the goal of Health for All by 2000 AD the WHO has listed the following four categories of indicators (Table 2).

TABLE 2

Indicators selected for monitoring progress towards Health for All

(1) Health policy indicators:

- political commitment to Health for All

- resource allocation

- the degree of equity of distribution of health services

- community involvement

- organizational framework and managerial process

(2) Social and economic indicators related to health:

- rate of population increase

- GNP or GDP

- income distribution

- work conditions

- adult literacy rate

- housing

- food availability

(3) Indicators for the provision of health care:

- availability

- accessibility

- utilization

- quality of care

(4) Health status indicators:

- low birth weight (percentage)

- nutritional status and psychosocial development of children

- infant mortality rate

- child mortality rate (1 -4 years)

- life expectancy at birth

- maternal mortality rate

- disease specific mortality

- morbidity - incidence and prevalence

- disability prevalence

 

The search for indicators associated with or casually related to health continues. It will be seen from the above that there is no single comprehensive indicator of a nation's health. Each available indicators reflect an aspect of health. The ideal index which combines the effect of a number of components measured independently is yet to be developed. While the search for a single global index of health status continues, the use of multiple indicators arranged in profiles or patterns should make comparisons between areas, regions and nations possible. In the last decade, attention has shifted from reliance on economic performance (e.g., GNP or GDP) towards other ways of measuring a society's performance and quality of life.

DEVELOPED AND DEVELOPING REGIONS

The world today is divided into developed and developing regions on the basis of some common features shared by them. The former is represented by countries such as USA and UK, and the latter by countries such as India. If one defined development as the organization of society to provide adequate housing, food, health services, education and employment for the majority of people, then many developing countries are wide of the mark. Social medicine is concerned with disparities that exist among countries. This is because socio-economic factors and .health problems are interlinked. An account of these disparities is given below:

1. Social and economic characteristics

Most people in the developing countries live in rural areas and urban slums. There is a rigid hierarchy and class structure moulded by tradition and long-standing customs. The family, often a joint family, is a strong binding force. People depend mainly on agriculture and there is a lack of alternative employment opportunities. The GNP per capita ranges from US $ 200 to 6000 in most developing countries. The; production and consumption per capita are low. They have an economic potential which is not fully realized; this refers to unemployed labour, natural resources and fertility of the soil. Science and technology are not fully applied. The level of literacy is low - it is only 49 per cent in the least developed countries and 38 per cent among women. The quality of life is poor because of the scarcity of essential-goods, facilities and money. There is isolation caused by distance, poor communications and transport facilities. The environment is unfavorable predisposing to communicable diseases and malnutrition. The vast majority of people are not able to pay for medical services. There is a long tradition of free medical services provided by the State.

In the developed countries, most people (8 out of 10) are urban residents. Urban life differs from that in the villages being more impersonal. Women are economically employed. Agriculture is second to industry. Great use is made of scientific disciplines. The standard of living and quality of life are high. The GNP per capita ranges from US $ 5000 to 40,600 in most developed countries. The adult literacy is almost universal.

2. Demographic characteristics

Population growth and changes have always been a central issue in community medicine. These changes have an impact on economic and social conditions and therefore on health and health care needs. The population of the world passed the 5 billion mark sometime in the middle of 1987. About 75 per cent of the world population lives in developing countries.

As the world population reaches 6 billion, the annual global rate of population growth is estimated to be 1.61 per cent. The advanced countries are failing to reproduce themselves, with growth rates less than 0.5 per cent, and some have already .achieved zero population growth rate (e.g., Austria, Belgium, Federal Republic of Germany and the UK). The rest of the world continues to reproduce at a prodigious rate. Rates over 2.4 per cent have occurred in some African (e.g., Nigeria, Zambia, Congo) and Middle East (e.g., UAE, Libya, Saudi Arabia, Iraq) countries. In India, the current growth rate Is about 1.85 per cent. These countries are now facing the population problem.

The population in developing countries is a "young" population; the proportion of persons under 15 years of age is about 35 per cent, compared to about 21 per cent in developed countries. The proportion of people over 65 years in developing countries is about 4.9 per cent, compared to 14.5 per cent in the developed countries. The social and economic backlashes of this age distribution are being felt in both the developing and developed countries the former having to bear the heavy burden of providing for a population which is mainly young; and the latter having to deal with the problems of aging.

3. Contrasts in health (Health gap)

While accurate statistical data are difficult to obtain, even perfunctory glance at available data (Table 3 and 4) are sufficient to illustrate the wide health gap between population in the developed and developing countries.

Table 3 shows that the present gap in life expectancy at birth between developed and developing countries is 15-20 years. Developed countries are characterised by longer life expectancy and lower infant and child mortality rates, and the opposite ii true of developing countries.

 

TABLE 3

Selected health and socioeconomic indicators

 

Least

developed countries

Other developing countries

Developed countries

l. Life expectancy at birth (1999)

51

63

78

2. IMR (per 1000 live births) (1999)

104

63

6

3. Under 5 mortality per 1000 live birth (1999)

164

90

6

4. Maternal mortality per 100,000 live births (1990)

1050

350

13

5. Doctor-population ratio per 10,000 (1993)

1,4

8,4

25,2

6. Nurse-population ratio per 10,000

2,2

9,6

74.2

7. GNR per capita {US $) (1999)

261

1222

26157

8. Per capita public expenditure on health. US $ in % of GDP (1999)

5

4

14

9. Adult literacy rate (%) (1999)

53

84

96

10. Per capita calorie (1996)

2095

2628

3377

11. Access to safe water (2000) % population

77

81

100

12. Access to adequate sanitation (2000) % population

46

59

100

 

Table 4 shows the familiar divergence of cause of death between developing and developed countries. Some 43 per cent (17,16 million) deaths in developing countries in 1995 were due to infectious and parasitic diseases compared with only 1,2 per cent (0,15 million) deaths in developed countries. 24,5 per cent of developing country deaths were due to arterial diseases, and only 9,5 per cent due to cancer - against 45,6 per cent and 21 per cent respectively in developed countries. But increasingly, health problems more associated with developed countries are beginning to show up in developing countries. Smoking is decreasing in many developed countries due-to health fears, but it is on the rise in developing countries: recent surveys have shown that more than two-thirds of men in India, Bangladesh, Indonesia, Thailand and Nepal smoke.

To sum up, the world health situation leaves much to be desired. Over 1000 million people in the developing countries have incomes too low to ensure basic nutrition and have little access to essential health services. In a number of industrialized countries, rapid increases in health cost have called into question the relationship between health care and health indicators. A search for alternative approaches has led to the view that primary health rare is the most important means whereby the health sector, with intersectoral coordination, can close the health gap and improve the Health status of the population.

 

TABLE 4

Proportion of total number of deaths. (996) in major categories of causes

(in thousands)

Category

Developed countries (%)

Developing countries (%)

World

No

(000)

 

%

Infectious and parasitic diseases

1,2

43,0

17312

33

Diseases of the circulatory system

45,6

24,5

15300

29

Cancers

21,0

9,5

6346

12

Diseases of the respiratory system

8,1

4,8

2888

6

Perinatal and neonatal causes

1,0

9,1

3745

7

Maternal causes

0

1,5

585

1

Other and unknown causes

23,1

7,7

5361

12

 

Methodology of morbidity study (general, with the temporal disability)

Morbidity of population is a collapsible concept that includes values, which are characterizing the level of different diseases and their structure among all population or its separate groups on the given territory.

In the complex of medical values of the health the morbidity takes a special place, its medical and social value is determinate by the fact that disease is the principal reason of death, temporal and permanent disability that by the turn results big economical losses of society, the negative influence on the health of future generations and diminishment of population quantity.

Materials about the level and structure of the morbidity in different regions, and also in separate sexual-age groups, especially in a dynamics for the definite period of time, are necessary for aimed programs development as for strengthening of health, in particular in planning of network developing of curing and prophylactic establishments and medical personnel training.

Also it is important that the values of the morbidity are one of the most informing criterias of activity of organs and establishments of the health protection and efficiency of conducting of medical, prophylactic, social and other measures care.

Finally, their studying determinate the ways of prophylactic of different diseases.

The statistics of morbidity in a great deal complements the statistics of death rate at estimation of population health and takes important advantage comparative with it, mainly effectiveness. At the same time, unlike the demographic phenomens (birth, death), which are easily determinate, the studying of morbidity is connected with considerable difficulties. The disease can have the indefinite beginning as well as the end indefinite in time. Its possible to observe "erased" forms of disease, bacillus carrying that can be difficult to distinguish the disease and the morphological, skeletal changes etc.

Besides the population does not always appeal for medical help. The disease mostly becomes accessible for registration only when the patient applies for it. As a result plenitude of information about morbidity foremost depends from the volume and character of medicare, its availability and quality.

The main methods for studying the morbidity are those one, which foresee the use of such given:

- appeals for medical help in medical establishments;

- medical examinations of separate groups of population;

- about the reasons of death;

- questioning of population;

- special selective researches.

Each method has advantages and disadvantages which are taken into account in practical activity. Anyone of them gives the exhaustive picture of population morbidity. Only their united using can give the complete information (table 1).

Table 1

Comparative description of basic methods of studying

the population morbidity

 

Name of method

Advantages of method

 

Disadvantages of method

1. Method of registration

availability for all layers of population;

aninterrapting and dynamics of supervision the state the health of population;

effectiveness of diseases account;

most complete account of acute diseases;

possibility of selection of the diseases first registered during the year;

much more economy

 

incomplete account of chronically diseases:

incomplete account of initial symptom less stages and forms of diseases;

incomplete account of diseases in cases: insufficient availability of medicare, insufficient plenitude of diseases registration and degree of specialization of medicare, bad sanitary culture of population; during service of population in private medical establishments

2. Studying of the morbidity according the results of medical examinations

                   almost a complete account of chronically diseases; exposure of diseases on initial stages;

                   the independence of examinations results from availability of medicare, sanitary culture of population etc.

impossibility of account of acute diseases;

scope of only separate groups of population: children, young people, workers of some professions;

high price

 

The method of morbidity studying of the appeals for medical help is most acceptable. It is related to obligatory registration of diseases that is caring out in state curing and prophylactive establishments. But plenitude of information, about the morbidity of population after the method of appeals can be limited:

at insufficient availability of medicare (for example, in rural locality);

bad level of medical culture of population;

insufficient authority among the population of medical establishment on the whole or separate doctors etc.

The study of morbidity from materials of appeals aloud us most to take into account the so-called "acute" diseases more completely. This method does not need additional facilities.

At the studying of morbidity from data of medical examinations, plenitude of information about morbidity depends on:

their systematic providing;

participation of doctors of necessary specialties;

sufficient diagnostic providing;

the control of timeliness and plenitude of examinations.

Using this method the most complete account before the unknown chronically diseases is provided, or those, which the population actively does not apply to the medical establishments. The advantage of this method is also exposure of initial forms and stages of diseases, clarification of diagnosis of some chronically diseases etc.

The studying of morbidity from data of death reasons is the additional method for two mentioned above. It is especially actual in relation to the account of those diseases, which are possible to be registered only at the appeal for the getting the medical certificate about the death (the question is about the patients, that had never appeal to the medical establishments and died at home), and also suddenly diseases which are given high lethality and were not exposed by the both first methods (heart attacks, strokes, traumas etc.)

If during previous years the methods of morbidity studying from data of appeals and medical examinations were leading, in modern terms, in case of the considerable number of private medical establishments and especially at introduction of elements of insurance medicine, the most complete information about the morbidity can be obtained from datas of the special selective researches and questioning of population.

The advantage of the questioning method is the possibility of account of diseases, with which the population does not apply on those or other reasons for medical help, and also finding out of opinion of man in relation to the disease.

At the same time the subjectivity connected with the self-diagnostics and also with the considerable quantity of wrong answers for the questions of questionnaire is appropriated to it.

Studying of the morbidity with the use of separately each of the indicated datas does not give the picture of actual exhaustive prevalence of pathology. Special selective, deep researches answer these tasks more completely. During their conducting the regional, sexual-age features of the morbidity are determined at different levels of the medical providing.

The selective special researches, including the morbidity of population, make it possible to obtain more detailed and high-quality information in more short terms and for less facility. Wide distribution of them is proposed by Program of reformation of state statistics on a period till 2000, by Decision of Cabinet of Ministers of Ukraine 971 from June, 22, 1999.

The selective special researches are part of the programs of deep study of health, which are used during enumeration population.

The last researches of this kind were timed in Ukraine to the All-union censuses of population in 1970 and 1989. Because of the wide-Ukrainian census of population in 2001 duty full research of morbidity is planned within the limits of the general program of determination the Ukraine population health.

In most foreign countries the selective study of document about hospitalization of patients and questioning of selective groups in population with application of questionnaire method are used for description of morbidity.

The study of general morbidity from data of general practitioners, organs of social insurance etc. is held only in some countries.

In Great Britain, where the state system of health care exists, researches of general morbidity on the basis of records of general practitioners are conducted.

Most economic developed countries use other information - questioning (interview) of selective groups of population. So, in the USA permanent researches of health of population, since 1958, include the study of morbidity on the selective aggregate of families by a questionnaire which contains over 40 questions in relation to family members: their diseases, got medicare, used medicines etc. The method of conducting such researches in the USA at the years is perfected every year, a few specialized "Centers of the control of morbidity" are engaged in their co-ordination, which, apply an interview by phone, and also departures of the special brigades which conduct the instrumental methods of inspection, besides the questioning of population.

Japan conducts the study of morbidity by means of the method of questioning the population of selected districts. Answers about the suffered diseases which took place only 2 months before the questioning are registered.

Researches, which are conducted in Denmark, France, are also based on questioning of population after the special questionnaire.

The necessary condition at the study of health of population, in particular morbidity, is the standardization of approach of doctors of different countries to determination and formulation of diagnoses that enables to compare morbidity in time and in different regions.

As its known, there are about 5000 diagnostic terms, which are used by doctors in practice. Evidently, statistical development of information about morbidity is not possible without the rationally built groupment that is the classification and nomenclature of diseases.

The project of international nomenclature and classification of diseases was ratified in 1900 at International statistical conference in Paris, which collected representatives from 26 countries. In future international classifications from time to time were looked through and were changed accordingly with progress of medical science. It took place approximately every 10 years.

Since 1962, International classification of diseases, traumas and reasons of death (ICD) is used in our country. ICD is periodically looked through and adopted by the special committee of experts on medical statistics and subcommittee of diseases classification of World health care organization (WHCO).

International statistical classification of diseases of the last Tenth revision (ICD-10) was ratified by the forty-third Assembly of WHCO January, 1, 1993. In obedience to the decision of the Assembly the document has a new name "International statistical classification of diseases and close problems of health protection", though the comfortable abbreviation ICD is preserved (table 2).

 

Table 2

INTERNATIONAL CLASSIFICATION OF DISEASES BY 10TH REVIEW (ICD-10)

 

1

INFECTIOUS AND PARASITOGENIC DISEASES

2

MALFORMATIONS

3

DISEASESS OF BLOOD AND HAEMOPOETIC ORGANS AND SOME DISORDERS WITH IMMUNE MECHANISM

4

ENDOCRINE DISEASES,DISORDERS OF NUTRITION AND METABOLISM

5

DISORDERS OF PSYCHICS AND BEHAVIOUR

6

NERVOUS DISEASES

7

EYE DISEASES AND ITS SUPPLEMENTARY APPARATUS

8

DISORDERS OF THE EAR AND MASTOIDEUS PROCESUS

9

DISEASES OF CIRCULATORY SYSTEM

10

DISEASES OF RESPIRATORY ORGANS

11

DISEASES OF DIGESTIVE ORGANS

12

DISEASES OF SKIN AND SUBCUTANEUS FAT

13

DISEASES OF BONE-MUSCLE SYSTEM AND CONNECTIVE TISSUE

14

DISEASES OF URINARY AND REPRODUCTIVE SYSTEM

15

PREGNANCY,DELIVERY AND AFTER-DELIVERY PERIOD

16

SOME STATES THAT APPEAR IN PERINATAL PERIOD

17

INNATED DEFECTS OF DEVELOPMENT,DEFORMATIONS AND CHROMOSOMAL ABNORMALITIES

18

SYMPTOMS,SIGNS AND DEVIATIONS FROM NORMA THET ARE REVEALED AT CLINICAL AND LABORATORY INVESTIGATIONS AND ARE NOT CLASSIFIED IN OTHER HEADINGS

19

TRAUMAS,POISONINGS AND SOME OTHER CONSEQUENCES OF ACTION OF EXTERNAL FACTORS

BESIDES OF 19 DISEASES CLASES TO ICD-10 THERE WERE INCLUDED TWO ADDITIONAL HEADINGS:

20

EXTERNAL REASONS OF MORBILITY AND MORTALITY

21

FACTORS INFLUENCING ON THE HEALHT CONDITION OF POPULATION AND APPEARS TO ESTABLISHMENT OF HEALTH CARE

The basic principles of construction of International classification of diseases, traumas and reasons of death are the community of etiology or pathogenesis of diseases or combination of locally-etiologic and local-pathogenetic principles. Every class of diseases is distributed on groups, and groups - on headings. For example, IV class of diseases of the endocrine system, disorders of feed and metabolic disturbances has 6 groups:

diseases of thyroid;

diabetes mellitus;

violation of other endocrine glands;

insufficiency of feed;

obesity and other types of surplus feed;

metabolic disturbance.

The group of thyroid diseases has 5 headings:

syndrome of innate insufficiency iodine;

diseases of thyroid, related to insufficiency iodine,

and the conditions;

hypothyreosis;

thyreotoxicosis (hyperthyreosis);

thyreoiditis;

other forms of thyroid diseases.

The basic innovation of ICD-10 is the using of alphabet-digital code (that replaces previous digital), when two numbers of the code are reflected the certain letter of the Roman alphabet, and at a necessity of the greater working out in detail of heading its third number.

For example, class of diseases of the endocrine system, disorders of feed and metabolitical disturbances is marked by a three-digit code from 00 to 90. In the turn the diseases of thyroid have the codes from 00 to 07, diabetes mellitus 10-14 etc.

Code example after separate subheadings:

Thyreotoxicosis (hyperthyreosis) - 05, including:

Thyreotoxicosis with a diffuse goiter- 05.0;

Thyreotoxicosis with a toxic one-node goiter- 05.1;

Thyreotoxicosis with a toxic multi-node goiter - 05.2.

In Ukraine the ICD-10 introduction in curing and prophylactic establishments was begun from 1999, according to the Decision of Cabinet of Ministers after 326 from 01.05.93 "About conception of construction of national statistics of Ukraine and Government program of transition on the international system of account and statistics.

 

There are such kinds of morbidity at its study from the data of appeals for medical help:

1. general morbidity - the account of all diseases (sharp and chronic) which are registered at the population of certain territory for certain period of time;

2. infectious morbidity - the special account of acute diseases, connected with the necessity of the operative conducting of nonepidemical measures;

3. morbidity on the major nonepidemical diseases falls due the special account as a result of their epidemiology and social value (malignant new formations, tuberculosis, venereal, psychical diseases etc.);

4. hospital or "hospitalized" morbidity enables to learn composition of patients which were treated in permanent establishment;

5. morbidity with the temporal disability of workers and employees is selected as a result of its social and economic value.

Each of these types of morbidity is studied after certain registration documents and is estimated on different values (table 3).

Table 3

Basic sources of information and values, which characterize the separate types of morbidity

 

Methods of study, types of morbidity

 

Basic information sources

 

Basic values

 

From data of appeals for medical help

General morbidity

Statistical coupon for registration of final (specified) diagnoses

Coupon of ambulatory patient

The general morbidity (prevalence of diseases) Primary morbidity

Structure of general and primary morbidity

Infectious

Urgent report

Level and structure of infectious morbidity

Nonepidemic

Report about the important nonepidemic diseases

Level and structure of nonepidemic morbidity

Hospitalized patients

 

Statistical card of patient. that left permanent establishment

Level and structure of morbidity of the hospitalized patients

With the temporal disability

Bulletin

Number of cases of temporal disability (D) on 100 workers

Number of the calendar days D on 100 workers

Medium duration of one case D

From data of medical examinations (aimed, previous)

List of persons which are subject to the medical examinations

 

From data about the reasons of death

 

Medical certificate about death

Medical certificate about perynathal death

Medical assistants certificate about death

Values of level and structure of morbidity, that led to death

 

The general morbidity takes into account prevalence of all diseases among all population on whole and separate diseases in its certain groups on the given territory as a result of appeals.

Values of the general morbidity enable to estimate the levels of morbidity that were exposed and registered in ambulatory-policlinic establishments during a calendar year.

General morbidity is studied on the basis of current registration all primary appeals of patients.

The first appeal at the chronic diseases is considered the primary appeal in this year.

At the acute diseases, which can take place several times during a year, the first appeal concerning every case is taken into account.

The case of disease or trauma concerning which the patient appealed to medical establishment is taken for unit of supervision at study of general morbidity.

Two documents are the source about general morbidity: "Statistical coupon for registration of final (specified) diagnoses" (f. 025-2/) and "Coupon of ambulatory patient" (f. 025-6/, f. 025-7/).

The separate "Statistical coupon for registration of final (specified) diagnoses" with the mark "+" is filled on every case of acute disease. Code 1" is marked alongside with the name of diagnosis in "Coupon of ambulatory patient" at the sharp diseases. Thus, a several cases of acute diseases can be registered at one man for a year.

The diagnoses of chronic diseases are registered only one time for a year. If a diagnosis is set for the first time in life of patient - note "+" in the "Statistical coupon for registration of final (specified) diagnoses or code of "2" in "Coupon of ambulatory patient." If the diagnosis of chronic disease is set earlier, at the first visit of doctor each next year in the "Statistical coupon for registration of final (specified) diagnoses" the mark of "-" or code 3 in "Coupon of ambulatory patient".

Information of the mentioned registration documents above is basis for drafting of "Report about the number of the diseases, registered at patients, which live in the district of maintenance of medical establishment" (f. 12).

 

There are such basic values of general morbidity:

primary morbidity (d) - the level of t first registered diseases for a calendar year on this territory; all sharp and first set for a year chronic diseases are taken into account also:

general morbidity, or prevalence of diseases (rvlce) the level of all registered diseases for a calendar year: sharp and chronic (registered at the first appeal in a current year, and exposed both in current and in previous years);

structure primary and general morbidity of population.

There are terms recommended by MHCO.

The method of calculation of the values is represented on the picture 21.

 

Picture 21

The method of calculation of the values.

 

Name of values

Method of calculation

Primary morbidity

 

Amount of diseases which are registered first at current year (all acute + first exposed chronic diseases) 1000

Average annual quantity of population

General morbidity (prevalence of all registered

diseases)

 

Amount of all registered during this year diseases (acute + chronic, exposed both in current and in previous years) x 1000

 

Average annual quantity of population

 

Structure of primary, general morbidity (prevalence)

 

Amount of all diseases of this class, group, nosology form registered for a year

(first registered) 100

 

Amount of all (first) diseases registered for a year

 

 

Using of "Coupon of ambulatory patient extends possibilities of analysis of morbidity. It is possible to define the values of frequency of sharpening of chronic diseases also, separately level of the first registered sharp and chronic diseases etc by this document.

 

Infectious morbidity

There is the special account and accounting about the infectious diseases in our country. It is conducted with the purpose of prevention of distribution and appearance of epidemic flashes, and also prevention of the professional and food poisonings.

Such diseases are to be registrated and taking into account obligatory: abdominal typhus, paratyphus, other infections, caused by salmonellosis, brucellosis, all forms of dysentery etc. The list of diseases, which changes periodically, is regulated by MHP (Ministry of Health Protection) of Ukraine.

The order of extraordinary reports at especially dangerous infections in the case of appearance of them on territory of our country is set also.

The special account is demanded also for exposed infected and patient with AIDS that is regulated by the special instructional-methodical documents.

Every case of disease or suspicion on it is a unit of supervision at the study of infectious morbidity. "Urgent report about the infectious disease, food, acute professional poisoning" (f. 058/) is filled at the exposure of them, and it is a basic document for the study of epidemic morbidity.

The doctor of policlinic or other medical establishment must fill in the urgent report, regardless patient address. It is necessary to operate in the same way at the exposure of infectious disease at the person hospitalized for treatment to permanent establishment, or at the change of diagnosis of patient, that already is on treatment. The doctor of first-aid fills the urgent report.

In rural locality, besides the doctors of rural district hospitals and ambulatories, the managers of medical assistant-accoucheur units must report about these diseases.

The urgent reports in curing and prophylactic establishments are registered in the magazine of registration of infectious diseases. The medical establishment, that had done it, must fulfill a new urgent report on a patient about change of diagnosis of infections disease and send it to the sanitary-epidemiology station according with the place of exposure of disease.

All urgent reports must be directed to the sanitary-epidemiology station during 12 hours which provides the epidemiology inspection of center of infectious disease according with place of its exposure (regardless of place of patient residence).

The following values are used for the analysis of infectious morbidity:

frequency of the exposed diseases (correlation of their number to the quantity of population of this territory; values are calculated per 100 thousands of population);

seasonality (data about the number of diseases on months are taken as a basis. The indices of seasonal vibrations are correlation of data during month to average annuals);

frequency of hospitalization and plenitude of it embrace (in the first case it is correlation of number of hospitalized persons to the quantity of population, in the second the correlation of the number of hospitalized persons to the number of exposed diseases in percents);

frequency of diseases after age, sex, profession (correlation of diseases number in the each group to the quantity of population of this group):

number of exposed bacillus carriers on 1000 inspected persons.

 

Morbidity on the major nonepidemic diseases

Some nonepidemic diseases are the subject of the special account:

                   malignant new formations;

                   psychical diseases;

                   venereal diseases;

                   active tuberculosis;

                   difficult mycosis.

The necessity of the special account of the indicated diseases is conditioned by:

                   the high level of distribution;

                   considerable frequency of death rate at some of them;

                   epidemiology meaningfulness;

 

                   a social conditionality.

As a rule, early exposure and comprehensive inspection, active dynamic supervision about patients, special treatment and exposure of contacts are necessary at these diseases.

 

There are two basic documents for registration of nonepidemic diseases:

1. The report about a patient, to which the diagnosis of active tuberculosis, venereal disease, tryhofitis, microsporias, favus, scab, trachoma, and psychical disease is set for the first time in life (f. 089/).

2. The report about a patient, with diagnosis of cancer or other malignant new formation set for the first time in life (f. 089/).

 

They are filled by the doctors of all curing and prophylactic establishments which for the first time set the indicated diseases at the appeal of patients to the policlinic, at the examination of them in permanent establishment, at the visit of patient at home or at a prophylactic medical examination.

Both noted documents are passed to the proper type specialized dispensaries (tuberculosis, oncologic, dermo-venerology, psychoneurological) which conduct an account and analysis each of its type, calculating the values of frequency and structure of exposed pathology on the whole and on separate classes, groups, nosology forms.

MHP of Ukraine confirmed a new registration statistical form 025/3-0 "Report about a patient with the set diagnosis of heart attack of myocardium, stroke with high blood pressure, diabetes mellitus" with the purpose of perfection of registration of separate diseases in medical establishments by the order 218 from 21.10.93.

A document is making by doctors of policlinic, doctors of first-aid and urgent medical help, pathologists, judicial medical expert and mailed in a three-day term to regional (city) cardiodyspansery (heart attack of myocardium, stroke with blood pressure high) and endocrinology dispensary (diabetes mellitus).

 

Hospital, "hospitalized" morbidity

This type of morbidity aloud to conduct the account of patients that had been treated in permanent establishments during the year.

The unit of supervision during its study is every case of hospitalization of patient concerning the disease, and information source is the "Statistical card of patient, that left permanent establishment".

This document is filled by a treating doctor at registration of the "Medical card of in-patient" in the day of his leaving or in the case of death.

Information about morbidity of hospitalized patients makes it possible to do the conclusions about its timeliness, durability and results of treatment, the volume of hospital help that was given etc.

Data about the "hospitalized" morbidity are taken into account at planning of bed fund, determination of necessity in different types of stationary help.

 

 

Morbidity of the hospitalized patients is studied on such values:

frequency of hospitalization (the relation of number of hospitalized concerning the certain disease or all hospitalized in a calculation on the quantity of population, that lives on this territory);

 

level of hospitalization after age, sex, the place of residence (relation of number of the hospitalized patients of this group in a calculation on the quantity of population of this group);

 

structure of hospitalization (specific case of every disease among the common amount of the hospitalized patients; it is possible to calculate the structure of hospitalized after age, sex, the place of residence);

 

medium duration of treatment (relation of number of the bed-days conveyed by patients in permanent establishment, to the number of the patients that left): this value is expedient to connect with the age of patients, diagnoses, the results of treatment and to analyze separately for written out from permanent establishment and deceased patients.

 

 

Morbidity with the temporal disability

The morbidity with the temporal disability is studied among working persons and is taken into account the cases of diseases, the result of which is missing of work time. This type of morbidity makes from 25 to 75 % of primary appeals for medical help.

The morbidity of working persons brings societies over considerable economic losses. That results the large social-economic value of this problem.

Official statistics of temporal disability in communication with the diseases were entered in USSR in 1925.

The case of disability is unit of account.

The registration document for registration of each case of temporal disability of a worker during the year is a bulletin.

A worker must give to administration of enterprise or organization the bulletin given by medical establishment after convalescence. The bulletin must contains the data about patient and every page in it is marked number of the case of disability, name, surname of patient, his address, place of work, diagnosis, surname of doctor, durability of release from work.

"Report about the reasons of temporal disability" (f. 23-D) is made on the basis of the registration data. It contains the data about the number of cases and calendar days of disability in relation to the most widespread diseases, in connection with the care of patient, with vacation at pregnancy and births, sanatoria-resort treatment etc.

A report is made by medical-sanitary parts, medical bases of health protection, district hospitals, policlinics and ambulatories, city and central district hospitals, other curing and prophylactic establishments of the system of MHP in Ukraine regardless of department subordination.

Medical establishments make a report about the reasons of temporal disability of working persons on enterprises, in establishments, organizations, which are on territory served by them.

The city and regional information-analytic centers of medical statistics make lists of selective circle of enterprises and organizations, overcoming not less % working persons in each of basic industries of national economy. Enterprises which have the basis of health protection are included in lists mainly. The general requirement to the enterprises, which are in the selective circle, is their proof vital functions in the conditions of competition.

All medical establishments, without the exception, reports after a form 23-D about the reasons of temporal disability of workers of health protection.

The basis for drafting of report is the bulletin, handed over in a current period. All sick-leave authorizations, given out by medical establishments both after job and domiciliary works and employee, and also after the place of their sojourn in the period of business trip, vacation etc., are included on it.

Primary reports about temporal disability are made on every industry of national economy separately (nuclear power plants, coal, chemical, petrochemical and easy industry, machine building and metallurgy, health protection etc.) and send to the district (city) central hospitals.

District (city) central hospitals make the taken reports on basic industries of this district (cities) and give them to organ of management by the health protection territory (Republics Crimea, regions, cities Kiev and Sevastopol). They send the territorial taken report to Management of statistics of territory and information-analytic center of medical statistics of MHP of Ukraine.

 

Morbidity of working persons with the temporal disability is analyzed on such basic values:

 

Value of cases of temporal disability on 100 working persons

=

Absolute number of cases at temporal disability

100

Medium quantity of working persons

 

 

 

Value of calendar days

temporal disability on 100 working persons

=

Absolute number of calendar days of temporal

disability - 100

Medium quantity of working persons

Medium duration of case of temporal disability

=

Number of calendar days of temporal disability

Number of cases of temporal disability

 

Value of structure of morbidity with the temporal disability

=

Number of cases (or calendar days) of disability from this disease 100

Number of cases (days) of disability at all diseases

 

The deep account morbidity with the temporal disability is conducted mainly on large enterprises for finding out of influencing of work terms on a health working, estimations of efficiency of health measures.

The account of diseases of working persons, which means establishment a card for every working person that contains about all cases of disability for a year with their basic descriptions (diagnosis, duration, place of delivery of bulletin) is placed in its basis.

 

Such account makes possible to get additional information about:

        those, who was ill often or during a long period of time for a year;

        specific part of persons which were ill for a year;

        specific part of working persons, which were not ill during a calendar year (index of health).

 

Such criterias are used at the selection of group those that often and during a long period time are ill:

        etiologic factor;

        number of cases of disability;

        number of days of disability.

 

The group of persons, which often were ill, is determined at presence of:

4th and more of cases of the etiologic connected diseases for a current year,

6x and more of cases of etiologic unconnected diseases for a current year.

 

The group of persons, that were ill during a long period of time during a current year, includes those who:

had sick-leave authorizations by duration more than 40 days in connection with the etiologic connected diseases;

had sick-leave authorizations by duration more than 60 days and more in connection with the etiological unconnected diseases.

 

Main resources of the information and indices that characterize some kinds of morbidity

Method of the studying, kinds of morbidity

Main information resources

Main indices

1.

According to the appealing for a medical help

 

 

1.1.

General morbidity

Statistics ticket for registration of the conclusion (definition) of the diagnosis. Ticket of the ambulatory patient

General morbidity (spread of the morbidity). Primary morbidity. Structure of the general and primary morbidity

1.2.

Infectious

Emergency notification

Level and structure of the infectious morbidity

1.3.

Nonepidemic

Notification of the important nonepidemic morbidity

Level and structure of the nonepidemic morbidity

1.4.

Hospitalized

Statistic card of the patient, outgoing hospital

Level and structure of the morbidity of the hospitalized patients

1.5.

With the temporary disablement

Card of disablement

Quantity of cases of temporary disablement (TD) per 100 of employers. Quantity of calendar days of (TD) per 100 of employers. Average term of one case of TD

2.

According to the information of medical checking (purpose, previous, periodical)

Lists of persons who have to be checked

 

3.

According to information about the reasons of death

Doctors certificate of death. Doctors certificate of perinatal death. Doctors assistant certificate of death.

Indices of level and structure of the morbidity, that caused death.

 

The methods of calculation of morbidity indices

 

Index

Methods of calculation

Primary morbidity

The quantity of diseases registrated in a certain year

(all acute +firstly acknowledged chronic diseases) x1000

Average year quantity of people

 

General morbidity

The quantity of diseases registrated in a

certain year (acute +chronic diseases) x1000

Average year quantity of people

 

Structure of the primary morbidity

The quantity of all firstly registrated diseases of a

certain class, group, nosological form during a year x100

The quantity of all firstly registrated diseases

during a year

 

Structure of the general morbidity

The quantity of all firstly registrated diseases of a

certain class, group, nosological form during a year x100

The quantity of all registrated diseases

during a year

 

Morbidity revealed during the professional examination

The quantity of all diseases revealed

during the professional examination x1000

The number of all examinated persons

during the professional examination

Exhaustive morbidity

The quantity of all diseases revealed during

the professional examination + the quantity of

all diseases according to the data of appeals x1000

Average year quantity of people

 

ECRR: Chernobyl 20 Years on. The Health Effects of the Chernobyl Accident

This is a summary of Chapter One of the ECRR book. It was prepared as part of LLRC's complaint to the BBC's Editorial Complaints Unit about a documentary, Nuclear Nightmares transmitted 13th July 2006 as part of the BBC's science output.

The following is not intended to be scientifically robust it's just a guide to the contents. For detail please refer to the ECRR 2006 or the original researchers. The health conditions are listed in the order they appear in the book. The presence of a condition here indicates that the parameter has worsened since the accident and many of the studies report a dose dependent relationship.
Direct quotes are italicised.

                     Stillbirths, miscarriages, infant mortality, general mortality, cancer mortality, sudden deaths.

                     Thyroid cancer.

                     The 40 % increase in all malignancies between 1990 and 2000 correlates with radioactive fallout levels. The list of cancer sites includes retinoblastoma, lung, intestines, colon, kidneys, female breast, bladder, respiratory organs, nervous system, pancreas, all cancers in children.

                     Psychological diseases correlate with levels of radioactive pollution. There is a steep and continuing increase in diseases of the nervous system, e.g. congenital convulsive syndrome, brain circulation pathology, general neurological diseases, short-term memory loss, deterioration of attention function in school-children.

                     In adults there is growing evidence of a syndrome marked by deteriorating memory and motor skills, occurrence of convulsions, and pulsing headaches. This is caused by the destruction of brain cells and in the region has been dubbed Chernobyl dementia.

                     In the Chernobyl territories cataracts have become a common disease.

                     Urogenital illnesses correlate with levels of radioactive pollution, and include interruption of pregnancy, gestosis, premature birth, inflammation of female genitals, ovarian cysts, uterine fibroma, menstrual irregularities, kidney infections, kidney stones, stones in urinary passages, infringements of sexual development, complications of pregnancy and births, failures of pregnancy, medical abortions, infertility, pathology of sperm, sclerocystosis, early impotence in men aged 25 - 30, structural changes of testiculus, spermatogenesis disturbances, lactation in 70- year old women, and delayed puberty as well as accelerated sexual development.

                     Diseases of the cardio-vascular system and blood are one of the most common consequences of the Chernobyl radioactive pollution:- anaemia, illnesses of the blood circulation system, arterial hypertensia or hypotensia, disturbances of heart rhythm and digestive systems, macrocitosis of lymphocytes, diseases of the blood and circulatory organs in adults, early atherosclerosis and ischemic heart disease, leucopenia, infringement of the blood supply in legs, changes in abundance and activity of leukocytes.

                     There is much evidence correlating fallout levels with endocrine/hormone diseases, e.g. incidence rate for Type 1 diabetes mellitus in Belarus. Similarly thyroid gland diseases (autoimmune thyroiditis, thyrotoxicosis, diabetes etc.). In 1993 more than 40 % of the surveyed children in the Gomel area of Belarus had an enlarged thyroid gland. Experts think up to 1.5 million people in Belarus are at risk of pathology of the thyroid gland.

                     In some of the Chernobyl-polluted territories immune systems are compromised, with changes to cellular and humoral immunity, decreased maintenance T- and B- lymphocytes, reduced resistance to infections and other diseases, raised frequency and expressiveness of tonsillitis, lymphadenopathies and lowered resistance to cancer.

                     In the radioactively polluted territories the typical consequence of infringement of the immune system appears as an immuno-deficiency. An increase in frequency and intensity of both acute and chronic diseases is observed everywhere in the Chernobyl polluted territories. Sometimes the weakening of the immune system in these radioactively polluted territories is referred to as Chernobyl AIDS.

                     There is accelerated ageing among the people in radioactively polluted territories in the Ukraine: their biological age exceeds their actual age by 7 - 9 years. In highly polluted territories in Belarus the mean age of men and women who died from heart attacks was 8 years younger than the average across Belarus.

                     The array of diseases commonly considered exclusive to the elderly is now typical for children in all of the heavily polluted territories. The immune system activity of these children is similar to the type of immune system activity experienced in old age. The pathology of the digestive system epithelium in children from the polluted areas of Belarus also shows similarities with elderly people.

                     There are many studies showing a wide range of chromosomal aberrations in the Chernobyl radioactively polluted areas. Examples:- higher frequency of chromosomal aberrations in somatic cells, lowered mitotic index in polluted districts, increased mutation rates in satellite DNA, chromosomal aberrations and satellite DNA mutations increased in children with thyroid cancer, chromosomal mutations de novo higher in polluted territories.

                     In the polluted territories, compared with clean ones, there is increasing morbidity by intestinal toxicosis, gastro-enteritis, dysbacteriosis, sepses, respiratory viruses, herpes infections, trichocephalisis, pneumocistis, cryptosporidosis, tuberculosis, viral hepatitis, cytomegalovirus (CMV) infection. Microsporia occur in the radioactively polluted territories of the Bryansk areas (Russia) more frequently and in a more virulent form.

                     There are increases in childrens general morbidity, and increases in rare illnesses in the Chernobyl polluted territories of Ukraine, Belarus and Russia; It is clear that children in heavily radio-polluted territories really do suffer, to a much greater degree, from a variety of diseases.

                     Practically all forms of studied nosology are more prevalent [] [there is] a convincing picture of sharply worsening health in children from the polluted territories. Conditions listed under this heading are:- chronic gastritis, chronic duodenitis, chronic gastro-duodenitis, bilious dyskinesia, vegeto-vascular and cardiac syndrome, astheno-neurotic syndrome, chronic tonsillitis, caries, chronic periodontitis.

                     Total child morbidity in Ukraine increased by 2.9 times between 1986 and 2001, newborn morbidity in Belarus increases year-on-year at a rate of 9.5% with greatest increases in the most polluted Gomel area. The spectrum of childrens non-cancer illnesses in the polluted territories includes lowered birthweight in those irradiated in utero in Ukraine, reduced head circumference in newborns in the polluted territories of Ukraine and Belarus, (this is known from Hiroshima also and is recognised as a radiation teratogenic effect), infringements of the rate of physical development in those irradiated in utero, premature birth more common in the polluted territories of Belarus, delayed rate of growth in the radioactively polluted parts of Belarus.

                     Respiratory system diseases occurred everywhere in the polluted territories and tend to correlate with levels of radioactive pollution:- asphyxia was observed in half of the 345 surveyed newborns irradiated in utero in Ukraine (presumably this was a study of peri-natal mortality). Other pathologies were latent bronchospasm, bronchial asthma, chronic bronchitis, chronic nasopharyngeal pathology, acute respiratory diseases.

                     Cardiovascular system diseases in children occurred more frequently in the polluted territories, including infringements of cardiac rhythm, infringements of vegetative regulation of cardiac activity, arterial hypertension, reduced numbers of B- and T-lymphocytes, lymphopenia, brachycardia, lymphoid hyperplasia, haematological disease, heart conductivity, and reduced elasticity of arterial vessels even in apparently healthy children.

                     Dental diseases in children are more frequent in the Chernobyl radioactively polluted territories. The frequency of some dental diseases correlates with levels of radioactive pollution.

                     Congenital malformations. Increased rates of teratogenic effects reported all over Europe, with a dose dependent relationship found in a Bavarian study. In Europe there were also widespread increases in still birth, premature birth, low birth weight, Down's Syndrome, perinatal and neonatal deaths, and reduced birth rate. In Belarus, according to the Belarus National Genetic Monitoring Registry, there were post-Chernobyl increases in anencephaly, spina bifida, cleft lip, cleft palate, polydactyly, limb reduction, oesophageal atresia, anorectal atresia and multiple malformations. Many of the authors explicitly state that these phenomena are radiogenic. One, a researcher known for her caution, says only a third of congenital deformities of the face and jaw could be attributed to radiation. But it is a third, and those which are so attributed are said to be anomalously severe.

                     The proportion of children with impaired intellectual development is consistently greater in polluted areas. Irradiated children have not kept pace with other children. Disorders of intellectual development in children irradiated in utero in the polluted territories are described as the most tragic consequences of the Chernobyl catastrophes impact on health. The ECRR 2006 book has an entire chapter on the topic. Its author observes that the official French agency IRSN has recognised that the Central Nervous System is radiosensitive, while the Chernobyl Forum 2005 report has many gaps and even errors on mental, psychological and CNS effects, and even misrepresents WHO findings. Children irradiated in utero whose mothers had been evacuated or who lived in a zone contaminated with between 5 and 40 Ci/km2, suffered a greater frequency of neurotic disorders, CNS pathology and delay of mental development, compared with children in the less polluted areas of Belarus. The depression of intellectual development was massively greater in the irradiated group than in the controls; pathologies include neurotic disorders, asthenic syndrome, vegetative dystonia, CNS organic pathology, delayed mental development, EEG pathology, delayed development of speech, lowered psycho-emotional development, low IQ indices, deviations in mental development, memory impairment, immaturity for school, organic pathology of the brain, decreased and delayed psychomotor development, epilepsy and epilepsy-related conditions, and schizophrenia.

Overview of health in Lugyny district

Here are some health statistics for one remote Ukrainian administrative district from the Zhytomir area Lugyny district, which is not one of the most contaminated regions. Comparison is made between two years just before the accident (1984 1985) and 1995 - 1996, ten years after. All the medical information for this study was collected by the same people in the Central Hospital before and after the catastrophe, using the same equipment and the same protocols.

The proportion of detected tuberculoses which were of a very aggressive type doubled. Endocrine pathology in children increased 10-fold. Goitres were not registered before the accident but ten years later were found in 12 or 13 children per 1000. Neonatal morbidity increased between 4 and 13-fold. Total mortality increased from 10.9 per 1000 to 15.5. Life expectancy declined from 75 years to 65.

Life-expectancy remaining to a patient in Lugyny District after being diagnosed with lung or stomach cancer shrank from 38 62 months before the accident to 2 7 months afterwards. The CERRIE Minority Report (p. 126) observes that this reduction in life expectancy runs counter to the view that increased incidence of cancer since the Chernobyl accident has been an artefact caused by increased vigilance and hence better ascertainment. Some commentators (apologists for nuclear power) claim that if doctors do more screening, more thyroid cancer will be detected. However, better ascertainment ought to mean earlier detection and hence more effective treatment and a better prognosis. In the Lugyny overview we see a dramatically worse prognosis after a lung or stomach cancer diagnosis the average patient now survives for only 4 months, instead of between 3 and 5 years before Chernobyl. Only four explanations are readily apparent:

1.                doctors are not looking for cancer as assiduously as before Chernobyl, so they detect it very late in its course;

2.                treatment resources are much reduced;

3.                cancer patients fear that their cancer was caused by radiation;

4.                the post-Chernobyl cancers are of a more aggressive type.

The first of these is contrary to the general pattern. The second is possible and should be investigated. The third is, to put it mildly, contentious (nuclear apologists claim that the increase in ill-health in the region is caused by radiophobia). The fourth is consistent with many observations in the region including non-cancer diseases.