世界卫生状况英文报告(2)

　　Diabetes mellitus is a growing public health problem in both developed and developing countries. A recent WHO expert group estimated that more  than 100 million people will suffer from diabetes by the end of this  century - 85-90% with the non-insulin dependent form. In Europe the  prevalence of diabetes is 2-5% per cent of the adult population. In  India a quarter of the populationis affected by the age of 60, and 1 in 5  North Americans will acquire thedisease by the age of 70. One recent  estimate put the cost of diabetes in the USA alone, both direct and  indirect, at US $92 billion a year.

　　Mental ill-health is at the bottom of the medical pecking order. Only the most severe cases, such as schizophrenia or manic depression, receive  what minimal care there is, even in developed countries. There are  disturbing signs that society would sooner have such patients  wandering the streets homeless than provide them with the care they  need. The stigma of ‘madness‘is still a potent barrier in preventing ill  people from receiving help. Some500 million people are believed to  suffer from neurotic, stress- related and somatoform disorders. A  further 200 million are affected by mood disorderssuch as chronic and  manic depression. Mental retardation afflicts some 83 million people,  epilepsy 30 million, dementia 22 million and schizophrenia16 million.

　　Smoking is emerging as the world s largest single preventable cause of illness and death. WHO estimates that there are about 1.1 billion  smokers in the world today. About 800 million are in the developing  world - nearly three times as many as in developed countries. Smoking  already kills an average of 3 million adults a year worldwide. If  current trends continue, this figure is expected to reach 10 million by  the year 2020.

　　In the area of women s health and childbirth, the differences in maternal mortality between countries are shocking. In Europe maternal  mortality is 50 per 100 000 live births. In some of the least developed  countries the rate exceeded 700 maternal deaths per 100 000 births in  1991. In developingcountries 1 in 5 deaths of women of reproductive  age are due to complications of pregnancy and delivery. Half a million  women die every year from conditions which are easily preventable.

　　Health of the elderly

　　The increase in the number of old people in the world will be one of the most profound forces affecting health and social services in the next century. Overall, the world s population has been growing at an annual rate of 1.7% during the period 1990-1995 - but the population aged over 65 is increasing by some 2.7% annually. Of a world total of 355 million people over 65 in 1993, more than 200 million are in the developing world, where they make up 4.6% of the population, with more than 150 million in  developed countries, where the proportion is 12.6%. Although Europe,  Japan and the USA currently have the ‘oldest‘ populations, the most  rapid changes are being seen in the developing world, with predicted  increases in some countries of up to 400% in people aged over 65  during the next 30 years.

　　Alongside the increase in the number of people over age 65, there will  also be a dramatic rise in the numbers of ‘old old‘ - people over 80. In  1993 they constituted 22% of those over 65 in developed countries and  12% in the developing world. The world elderly support ratio (the  number of people over 65 years compared to those aged 20-64) in 1990  was 12 elderly to every 100 people of working age. It is estimated  that the figure will be 12.8 in the year 2000 and 13.2 in 2010. In other  words, while population increase during1990-2000 is estimated to be  17%, the increase in the number of elderly is likely to be 30%.

　　One of the most difficult questions for health planners and politicians trying to allocate funds, as well as for the community and individuals themselves, is whether increased life expectancy means more health  or simply more years of sickness. This is an area that is greatly  underresearched, yet the question is assuming ever greater importance.

　　Two of the most pressing problems in the future will be the provision of care for people with dementia and those needing joint replacements for arthritic diseases. WHO estimates that there are 165 million people in the world with rheumatoid arthritis. The long-term care of the frail elderly is becoming one of the most debated medical and political issues in many developed countries, and the developing world too will soon have to  wrestlewith it. If people are not to be left destitute and uncared for at the end of their lives, more attention must be given to social mechanisms for the support of the elderly and the means to fund them.

　　General health issues

　　Although in the past 10 years there has been a global trend towards the democratization of political systems, the much anticipated ‘peace dividend‘ has failed to materialize. Poverty has continued, and will continue, to be a major obstacle to health development. The number of poor people has increased substantially, both in the developing world and among underprivileged groups and communities within developed as well as developing countries. During the second half of the 1980s, the number of people in the world living in extreme poverty increased, and was estimated at over 1.1 billion in 1990 - more than one-fifth of humanity.

　　The changing demographic picture across the world, together with the  rapid shift towards urbanization, will have profound implications for  the delivery of health services. The unplanned and often chaotic growth  of megacities in the developing world will pose particular challenges,  as poor sanitation and housing encourage the spread of infectious diseases.

　　Against any optimism about the global economy throughout the remainder of this century and beyond should be set a number of major uncertainties. There has been a disproportionate flow of resources from the developing to the developed world - poor countries paying money to rich ones - because of debt servicing and repayment and as a consequence of prices for raw materials that favour the latter at the expense of the former. Structural adjustment policies aimed at improving the economic performance of poor countries have in many cases made the situation worse. The words of Robert McNamara, spoken in 1980 when he was President of the World Bank, still hold true: ‘The pursuit of growth and financial adjustment without a reasonable concern for equity is ultimately socially destabilizing‘.

　　A further worrying global trend is growing unemployment, especially in developing countries without social security arrangements to cushion those out of work. Long-term unemployment is creating a new class of ‘untouchables‘ - by excluding a large group of people from the mainstream of development and society. The unemployed are a potent reminder of the dangers of assuming that the general prosperity of a country will trickle down to all its members.

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