THE INFLUENCE OF WORLD TRENDS UPON HEALTH

Before discussing the influence of world trends upon health, consideration must be given to Health for All by the year 2000 - the challenge for the nurse .


HEALTH FOR ALL
B efore discussing the influence of world trends upon health, consider ation m ust be given to Health fo r A ll by the year 2000 -the challenge fo r the nurse.
As you will know, the W orld H ealth O rganisation has qualified the word health in this context, as follows: A level o f health that per mits the people o f the world to lead a socially and economically produc tive life. Some industrialised coun tries have slightly am ended th at d e finition to read a level o f econ omically productive life that would perm it people to maintain health. (1) T hat im m ediately m akes us think of that tragic trend which we are ex periencing, particularly in indus trialised countries, but one which will have enorm ous repercussions on the Third W orld also. T he trend is, of course, the increasing num ber of people who are unem ployed and therefore experiencing som ething which directly m ilitates against their achieving an economically produc tive life. In Britain alone, unem ploym ent has becom e a m onsteraffecting the physical and m ental health of millions. It is not only the num bers of unem ployed persons who suffer -their parents, sib lings, spouses, children and o th er dependants are also affected. B e cause of their consequent boredom , frustration and lack of appropriate outlets for adolescent energies, one most tragically also has to speak of their victims -the victims of their physical and m ental violence.
In 300 B .C . H erophilus set out, not a definition of health as the ab sence of disease, but m ore d ra matically described the absence of health. H e said: When health is absent. Wisdom cannot reveal itself. A rt cannot become manifest. Strength cannot fight. Health becomes useless. A n d intelligence cannot be applied.
In many of the developing coun tries of the world, we find that p ro gress tow ards achieving our desired goal of H ealth for All is slow. In the m ajority of cases it is very slow. Whilst m ost W H O m em ber states have enunciated plans and policies for prim ary health care -identified at A lm a A ta, as the key to provid ing health coverage -health ser vices of socially and geographically peripheral populations have not im proved significantly since that clar ion call to action four and a half years ago. In a recent edition of the W orld H ealth publication W orld Health Forum, R ichard Smith (who is D irector of H ealth M anpow er D evelopm ent at the U niversity of Hawaii, U .S .A . -an institution which has been widely involved in the health care program m es of many developing countries), writes: The second part of the subtitle the challenge fo r the nurse probably reflects, one of the reasons for this, for it is a well and frequently used phrase. So many sym posia, confer ences, m eetings, organisations and publications tell us that H ealth for All 2000 is a challenge -for which every section, discipline or profes sion is being addressed. T he trouble is that although so many people are busy throw ing down this particular topical gauntlet, no group appears anxious to pick it up.
It should thus be pointed out that the challenge fo r the nurse does not refer to a group: the challenge put out is not to nursing, nor even to nurses. It is to the nurse. You. Me. Each one of us -educator, adm in istrator, clinician, researcher, hos pital or com m unity practitioner, council or association m em ber. Today, the challenge is issued on the most personal level possiblethe individual.

WORLD TRENDS AND HEALTH
Let us now tu rn to the influence of world trends upon health -with particular reference to the d e veloping countries. It is only poss ible to suggest som e of these trends and even those, very briefly. The w riter trusts, how ever, th at they will suffice to produce a back ground canvas to paint som e of the various settings and activities which form the foreground -always keeping in sight the focal point of the picture and indeed the whole raison d 'etre of o u r existence as nurses -the p atien t, him or h er self. It is em phasised -the indi vidual nurse and the individual patient or the individual com m unity. F or the opposite denotes a tren d which can be seen as another reason for o ur ap p aren t failure. These days we are frequently sub jected to ex hortations concerning im a g in a ry h o m e g e n o u s g ro u p s som ew hat patronisingly nam ed the elderly, the handicapped, the m en tally retarded, the p o o r or the disad vantaged.
A t this tim e, w hen the w orldincluding the m ajority of U nited N ations and o th er international agencies -is already half-way down the collectivist slope, it is in teresting to note th at the two m ost popular people in the world are said to be the Pope and M other T eresa of C alcutta. O f the latter, we are told th at w hen she was asked, W ould yo u agree that one o f the m ain troubles o f the day is that 20th century m an always thinks in terms o f collective solutions? She replied, I do not agree with the big way o f doing things. I f we wait fo r numbers, then we will be lost in numbers.

MAN'S INCREASED KNOW LEDGE AND CONSEQUENT BEHAVIOUR
A lm ost all the health trends appear to be m an-m ade and are the result of m an 's increased know ledge and consequent behaviour. W ith the ex ception of natural disasters, such as floods, spontaneous fires, ea rth quakes, cyclones and the like, m an him self is responsible for his pres ent disastrous environm ental condi tions, his cu rren t dem ographic changes and, in d eed, in m any in stances for his own ill health.

Man victim of his own behaviour
Just a cursory glance at the most prevalent diseases and conditions in the w orld today show th at unlike m any patients of fifty or so years ago, who w ere often the victims of outside agencies, to d ay 's patients -with the exception of those with pathological changes brought about by ageing, and others who are con genitally disabled -are often vic tims of their own behaviour. O ne has only to think of heavy sm okers with cancer, o th er addicts of al cohol and non-therapeutic drugs; people m utilated or disabled by traffic accidents; young girls with septic abortions; people of all ages with sexually transm itted diseases; business executives with coronary heart disease, and the large num bers of elderly people alone or even isolated and with disabilities or handicaps which could have been controlled or even prevented at the im pairm ent stage. To put it an o th er way, much of the prevention of present day diseases and injuries is in p eo p le's own hands. T herefore, as health w orkers, we m ust work with them and not just for them . B ut, as yet, we have not succeeded either in m otivating them to m ain tain health, nor have we developed attractive, appropriate and com pre hensive learning program m es so that they know how to. M an is also not only injuring him self, he is in juring his fellow hum an beings. M an-m ade disasters, wars and con flicts, im prisonm ents and to rtu re are causing deliberate physical and m ental injuries to millions. They, together with som e of the natural disasters in recent years, have led also to m igrational trends which in turn have brought not only health and social problem s of housing, feeding and sh elter, but have also affected the p attern and transm is sion of disease throughout the world.
A ir travel, for business and pleasure, has likewise m eant that com m unicable diseases such as m a laria, or lassa fever once thought of as being confined to tropical climes, can now affect a suburban family living in a sophisticated com m unity in one of the so-called developed countries.
W hile m an has learned how the balance of n ature w orks, he has also learned how to frustrate its o p e r ation. By his m astery over bacteria, P an d o ra's box has been opened.
out of which has com e a population explosion far beyond the existing logistic m eans of food supply and its twin spirit pollution. M an cannot close the lid any m ore than could E pim etheus. All he can do is to com e to term s with the new p ro blem s and adapt his thinking and his planning to harness and control the new m onsters.

Increase in aged and disabled
T he reduction of infant d eath rates has had th ree im portant effects. First, in the m ore developed coun tries w here the reduction has been m ost startling, th ere has been access to family planning services, albeit haphazard. In these countries the birth rate has fallen to m atch the death rate and the ages of p o p u lations are rising slowly because people are living longer. If this p ro cess continues we know th at d e veloped countries can look to the day w hen half their adult po p u la tions will be past retirem en t age, and if the present trends in this field are allowed to continue, with all the social, econom ic, and health p ro b lems longevity brings. It has also been realised th at m ore than one third of the w orld's population in the year 2000 has yet to be born. 2,500-million of the projected 6000million will be under 21. W ho will be able to provide in the needs of the old?
Secondly, while these countries have been rem arkably good at d ea ling with the diseases people ac quire, they have been less good at dealing with those they inherit. O nce upon a tim e intercu rren t in fection kept down the num ber of people with severe defects, but now increasing num bers of physically and m entally disabled children are nu rtu red to adult life. T heir care in volves great dem ands upon sparce resources. P rem atu re babies or frail deform ed children are cocooned until they are fit to leave th eir ex pensive hospital units and life-supporting equipm ent and are then often destined to live for the rest of their lives in an institution which rates, in the m ajority of health ser vices, as the low est priority.
Having willed the end -survival -the com m unity has brought upon itself a duty to provide the means of a decent life. M ere survival is not enough.
A t the o th er end of the life span, advances in scientific technology m ean th at with the aid of organ transplants, clever m achines and all the ironm ongery of m odern medical practice, the frontiers of death have been pushed back. Having assured that we live on borrow ed tim e, does the achievem ent prove anything o th er than professional prowess and surgical dexterity? How often are limited health care resources allo cated to fund the intellectual exer cises of researcher and practitioner? A re we not caught in an interreg num ? . . . A kind of m oral and dem ographic no-m an's land?
Still concerned with saving life at any cost, we find ourselves with too few resources left over to ensure the quality of th at living. A t the present time in developing countries the problem , in Indira G h an di's words is not so serious. But even she, in her message last sum m er to the U .N . A ssem bly on ageing, points out th at it is likely to be serious very soon. Mrs G handi goes on to ex plain why . . . O ld people have been revered as elders and sheltered within the jo in t fam ily. Being in touch with several generations, seeing their fam ilies grow up around them keeps up their interest in life and issues. B ut industrialisation and modernity are beginning to disturb the pattern. Even here (India) the re spect and concern fo r the old, which were so m uch a part o f our tradition, is weakening.'3'

Changing fam ily pattern
The very fact that M rs G handi, like M rs T hatcher, is a Prim e M inister, focuses our attention on another strong influence on health. T hat is the changing family pattern in in dustrialised countries due to the socalled liberation of wom en. The em ploym ent of wives and m others and the appointm ent of some to high office has m eant th at fewer are at hom e to care for the very old, the very young and for the sick or dis abled m em bers of the family. Yet in the Third W orld, wom en have always u nd ertaken work o ther than that of a wife and m other. In India, for exam ple, w om en account for nearly half the labour force in the building industry. In fact, women put in two thirds of the w orld's w or king hours yet they receive 10% of the w orld's incom e and own less than 1% of the w orld's property. These facts are not produced by a w om an's organisation -they are produced by O X F A M , the U .K . based international relief organis ation and a charity, first set up to help with some of the problem s caused by fam ine and m alnutrition.

Malnutrition
This brings us to another great in fluence on the health of millions. M alnutrition is one of the greatest scourges of developing countries. In today's sem antics, there are grada tions of hunger -fam ine, starva tion, undernourishm ent and m alnu trition. O n mission for various o r ganisations the w riter has seen many of them -acute fam ine in East A frica, chronic fam ine and starvation in south-east A sia and the Pacific. She has seen hundreds, if not thousands of children m al n o u ris h e d o r u n d e r n o u ris h e d . Some she regrets to tell, have been the victims of relief agencies who have given out belly filling grains and o ther carbohydrates, deficient in protein, vitam ins and enzymes. She has also seen wom en who them selves are nothing but skin and bone, trying to give nourishm ent to their babies. W e all know how im portant it is to im press upon m others the value of breastfeeding, but after seeing wom en crum pled by osteom alacia, one cannot ignore the draconian law of nature by which a foetus is nourished and an infant is fed at the expense of the m other's skeleton. Let us consider a few of the trends which have led to this.
Before the Second W orld W ar, central Java was a proverbial rice bowl, able to feed its own people and exporting surplus rice to other Asian countries. A fter the W ar, its already intensive cultivation was in tensified. P easants responded to new ideas presented to them , and w ere diligent in their husbandry. They increased irrigation, and they responded to exhortations about green manure. They planted fish with their rice, putting fingerlings into the wet paddy and harvesting sizeable fish when the paddy was d r a i n e d . T h e y t h u s i n c r e a s e d productivity by 25% in 10 years. But during those sam e years the p o pulation increased by 30% . T hat 5% difference m eant chronic star vation with its stigm ata of m aras mus, kw ashiorkor, hunger oedem a, dehydration, blindness and other m anifestations of vitam in deficien cies. Similar stories can be told about countries of south-east A sia, Africa and Latin A m erica.
In B ritain, and in many o th er in dustrialised countries, the m ajority of people have too much food in general and too much of certain articles of food in particular, and excesses of sugar and unsaturated fat are thought to be pushing up the incidence of diabetes, coronary disease and tooth decay. A t the same time about 40% of the w orld's population eat less than 2200 cal ories per day and many 1500 or less. The picture regarding protein con sum ption is worse and is growing even m ore gloomy.
The result of these dietary fail ures is that in large areas the main source of ill-health is basically nutri tional and this predisposes to infec tion. In A frica, kw ashiorkor is w idespread; in rice-eating countries of A sia, vitam in B deficiency p ro duces beri-beri and m any o ther less bizarre sym ptom s, while in maizeeating countries, pellagra is still by no m eans unknow n. Rickets is still to be found w here children are d e prived of a balanced diet and where custom shields them from light. Iodine deficiency is thought by many experts to be the cause of a good deal of feeble-m indedness and cretinism in the world. G eneral avitaminosis and underfeeding ac counts for much ill health that is un classified, but which plays an im portant part in the m aternal and infant m ortality rates throughout the world.

Overpopulation
W hat the optim um population of the world should be, is hardly a profitable speculation. The purpose of child spacing is to limit popula tion to the resources available. At the present tim e, m any countries have slums and shanty towns teem ing with people who are unem ployed, ill-educated as well as underfed. D uring recent decades, there has been an enorm ous in crease in the num ber of these people in the poorer countries of the world. This growth is continuing and in som e instances accelerating. Today, m ore than one third of the people living in cities and in d e veloping countries live in slum dwellings.
The main reason for this growth is that large num bers of people are moving from the rural areas in search of w ork and a b etter life. M i grants, industrial w orkers, farm w orkers, seasonal w orkers and dis placed persons are a growing p o p u lation, all contributing to the swell ing of urban slums. If present trends continue, in 30 years' tim e, C alcutta will be a city with sixty-million people, while the total land area covered by cities will occupy one fifth of the w orld's surface. E xperi m ents with anim als show th at as l i v i n g s p a c e b e c o m e s m o r e cram ped, so the tendency to aggres sion rises. A t a certain level of stress and over-crow ding m uskrats kill each o ther. T he continuous herding of com m unities into insalu brious cities p o rten d s a rise in crime and violence -a rise th at is already sufficienty m anifest in m any cities of the world as to be extrem ely disturbing.

Drug abuse
A n o th er effect of over-herding, un em ploym ent, poverty, m alnutrition and o th er stresses, is th at m an has tried to find solace in his own perso nal form of pollution -tobacco, al cohol, or drugs. It is his last escaperoute. D rug abuse is not a new phenom enon -it has existed ever since m an discovered narcotics. Use and misuse have existed beside each o th er for centuries. U p to a few years ago, com m issions and con ventions, including the fam ous review at the 1931 B angkok C onfer ence, w ere m ainly concerned with opiates and cocaine and these are still the subjects of the principal pre-occupation of international con trol. B ut change is th e essence of life and the p attern of drug abuse is no exception to the rule. T here have been periodical changes in the past, but recent years have w it nessed th e m ost radical change of all. This has been the startling spread of misuse of cannabis and of o th er drugs which affect the central nervous system -the stim ulants, the depressants and the hallucino gens.
The g reater m edical profession (which includes nurses) is not en tirely blam eless. A n exam ple is the m anufacture of and prescriptions for drinam yl in the early 1950s which ushered in the pep pill era am ong teenagers. T he sam e period also saw the indiscrim inate use of antibiotic drugs which has led to the change in som e b acteria from drug susceptibility to drug resistance. T here has also been w idespread handing out of b arb itu rates, seda tives and hypnotics.
A p art from m edicinal, there is an increase in industrial, political and social uses of drugs. G re ater p ro ductivity in the farm ing industry by the adm inistration of drugs to p ro m ote grow th of farm anim als is an exam ple of o n e, and following the dictum th at w ar is an extension of politics, chem ical w arfare agents are an exam ple of another. Social drugs are those which are used nonm edically, and by self-adm inis tration, with the intention th at the effect will alter a p erso n 's m ood and m entality. This category includes m any substances of w idespread every-day use -tea, coffee, al cohol and tobacco -which for b etter or for w orse, are interw oven into the fabric of our societies.
As was said at the beginning, it is im possible to cover all the present day trends which influence our health. O ne has only to look at some of the issues being discussed in our daily new spapers, as well as in our professional journals, to real ise the effects of know ledge today. T he m isuse o f psychiatry, mass m e d ic a tio n ( f lu o r id e a d d e d to w ater, vitam ins to m argarines and calcium to flour), m arital pathohology, genetic engineering, the grow th of the trades union m ove m ent, the econom ic recession, the rights and the health of prisoners and detainees, the practices of euthanasia and abortion.

GENETIC, ECOLOGICAL AND CULTURAL LOSSES
The above deals mainly with the ef fects of m an's behaviour and health of his increased or newly acquired know ledge. B rief m ention should be m ade of the influence upon our health of genetic, cultural and eco logical losses.
In m any respects, industrial m an may be considered to be an aggres sive and successful w eed strangling o ther species and the w eaker m em bers of even his own. W e live in a world of exploitation. R esources are finite and soon even our present day, all-pow erful society will be forced to be conservationist. It is suggested th at people who live in areas w here conservation is necess ary have m uch to teach us. These people, to a large extent, are re presented by the rem aining tribal groups who have m anaged to avoid cultural and physical destruction by living in areas of the w orld which the ecologist calls marginal. This in cludes the extrem es of tem p eratu re and m oisture gradients with their correspondingly m ore delicate bal ance of nature. N ow , how ever, we with our new est technological feats stand poised to conquer this small final frontier.
A ppell has highlighted the alarm ing rate at which both the resources of our eco-system and the culturespecific know ledge relating to the resources, are rapidly being lo st. It is know n today th at th ree th o u sand-m illion years ago th e m ito chondria, the sub-m icroscopic p a r ticles through which the cells o f o ur body utilise energy and w ithout which we w ould be unable to con tract a m uscle o r express a thought, were separate organism s, probably bacteria, just like the plant chloroplasts that control photosynthesis and liberate the oxygen we need to live. M itochondria and chloroplasts began to live in symbiosis with o th er organism s. They have now becom e essential for the life of anim al and plant cells, which have them selves lost the pow er of living in d e p e n d e n tly /5* This is the way in which hum an society can be seenfor all life is a kind of symbiosis of that type. T he great danger is not th at m an fails to adapt to his en vironm ent, but th at, on th e con trary, he adapts to o easily.
O ne great problem of ou r tim e is to decide w hat we should refuse to adapt to. O ne exam ple is noise. O ne can becom e h ab itu ated to noise but only at the expense of dam age to the auditory organs. Likewise the body can also becom e accustom ed to air pollution, thanks to the bronchial secretions which protect it, bu t in the long term em physem a o r chronic bronchitis will result.
H ippocrates thought of health as an expression of the harmonius bal ance betw een the environm ent, hum an nature and the individual's way of life. H e described a good physician as one who has a due regard to the seasons o f the year and the diseases which they produce; to the states o f the wind peculiar to each country and the qualities o f its water; who m arks carefully the loca lities o f towns; the surrounding country, whether they are high or low, hot or cold, wet or dry; who moreover, takes note o f the diet and regimen o f the inhabitants and all the causes which m ay produce dis order in the animal econom y.
M edicine and nursing encom pass that com plex relationship of m an, his environm ent, his culture and physical and social pathogens. It is not lack of highly trained health w orkers, m oney and equipm ent that are the m ajor problem s p re venting us from achieving H ealth for All 2000. The basic problem s lie at the preventive level.

MEDICINE AND NURSING
T he last group of trends now con cerns the two main categories of health w orkers -doctors and nurses.
O ver the centuries nursing has developed as a response to chang ing social needs. In recent years it has m erely adapted -like m an, too easily -for it has adapted not to com m unities' needs but to the de m ands of medical technology. D uring the role-finding exercise that m ost categories of the greater medical profession have undergone during the last decade or so, nurses have suffered m ore than any group and we ourselves are largely to blam e. In hospitals and other i n s t i t u t i o n s w e h a v e c a u s e d o u r discipline to suffer a kind of ex change transfusion, accepting tasks traditionally regarded as the pro vince of doctors and rejecting basic nursing care. Today, nurses almost everyw here, u ndertake a disease, hospital and m edicine orientated education in ord er to becom e twiddlers of knobs and dials, w atch ers of m onitoring m achines, dis pensers of m iraculous drugs and as sistants at existence-prolonging sur gery.
Y et prim ary health care was d e scribed by a working group m eeting recently as an elaboration of the traditional roles and functions of com m unity nurses. By this ap proach nurses have opportunities and the m eans by which they can help to achieve for people an enjoy m ent of life in their own hom es with or w ithout disability and especially enable wom en and the very old to m aintain -or obtain -health. It is a tragic fact that in m any countries of the world few appear to be interested.
Let us turn to doctors. The lay population increases daily w hereas each new physician spends, not just nine m onths, but at least five years in the making! If all doctors were involved in the provision of direct health care and if they were all evenly distributed the world would have one for approxi m ately every two and a half th o u sand people -a very m anageable ratio. The real situation is o th er wise. R icher countries have one th o u s a n d -m illio n p e o p le a m o n g whom are one-m illion physicians. The rest of the world contains 2Vi times as many people and has ap proxim ately three hundred th o u sand medical practitioners.
A further com plication is their distribution within a country. In d e veloped countries doctors are not too unfairly divided betw een rural and urban areas, and for the m ajor ity of people there is little difficulty in travelling to a centre of medical excellence when they need to. But in developing countries, where large num bers of people live in rural areas and where transport is difficult and expensive at best and non-existent at worst, health pro fessionals tend to rem ain in the urban setting for which their socalled elegant training has equipped them , close to m odern technology and medical facilities and where they can enjoy the com paratively high standard of living and working conditions. T here are therefore many parts of the world where as many as hundred and fifty thousand people share, or rather do not share, the services of just one doctor. In some places this ratio may change to the incredible and sham eful one and a half-million hum an beings per physician.
Still an o th er trend adds to this deprivation, that of international m igration of both doctors and nurses. So the situation has d e v e l o p e d w h e r e b y d o c t o r s a n d nurses can be attracted by profess ional and m aterial rew ards into leaving their own and poor coun tries to fill gaps in the kind of health services sought by the m ore pros perous.
The trend has been of course to take just one of the eight aspects of com m unity o r prim ary health care as described in the A lm a A ta report and to use prim ary health care w orkers for this. Because of the very nature of key prim ary health care com ponents, m any w ere vague and purposely flexible. The injunc tion to prom ote com m unity partici pation therefore was open to national interpretation. It was also the easiest and the m ost econom ic to im plem ent. T he narrow objec tive of the m ajority of developing countries appears to be let us at least be seen to be involving the co m m unity. As a result varied p ro gram m es to develop a basic level of health w orker have been set in m otion.
Few have given attention to the absolute necessity of an appropriate infrastructure with referral and supervisory capacities, to the cri teria used for selection of suitable personnel, to the logistics for sup port and supplies, and to the im por tance of living and working condi tions/facilities so that the workers can practise their teaching. Illich's gospel of autom om y and the indi vidual's responsibility for its own body and health underscores the other W H O slogan Health by the People. Few have stopped to con sider w hether it is possible, on a sig nificant scale, for there to be health by the people unless their govern m ent's are also actively prom oting health for the people and their p ro fessional health w orkers are ac tively supporting health with the people.
H ealth care should entail a long term program m e involving the basic principles of identification with the com m unity; by sharing of ideas and decisions; and recognition of the in fluence of past culture, as well as current trends. U nless a health p ro gram m e develops from within the body of the com m unity and is of the com m unity, it will not succeed. T hat is the challenge -to each and every health w orker in the world today.