F.e.a.r.s  o.f   t.h.e  r.i.c.h  a.n.d

b.e.n.e.f.i.t.s   t.o  t.h.e  p.o.o.r

    To see medicine's most spectacular achievements you should look into the effects of preventive and public health medicine in developing countries. In the 20th century, people in these countries have witnessed the dramatic impact of scientific principles on high infant mortality and endemic infections. In due course, patterns of mortality in developing countries will begin to resemble those of the developed nations, with cancers and cardiovascular diseases displacing infections as the main causes of illness and death. Many of these liberated people, either through the absence of means or the lack of inclination, have so far failed to limit the growth in their numbers -- a catastrophe in the making.

    The triumph of death control in the absence of compensating birth control has long been socially contentious. Countless attempts at planning have been subverted by religions , political, economic, and other vested interest that portray population increase as acceptable or even desirable. All attempts to limit it is seen as conspirational or oppressive. Does population increase matter? What role can the medicine of the future have in dealing with it?

    Only the optimist can believe that population increase represents no conceivable threat. In 1995, there were around 5700 million, and by the end of the 21st century we may see a doubling or even a tripling of this number. More than 90 percent of the increase will occur in the developing countries, which are the have-nots of the planet.

Optimists say that poor countries of the southern hemisphere are undergoing the kind of transition that Europe experienced in the 19th century. Before that transition, high birth rates were balanced by high death rates; so the population grew very slowly. In the first stage of this transition, death rates decrease as a result of the improvement in heath and living standards, but because the birth rate remained high, the population increases. Not until the third stage of this transition will the gains of economic development allow the birth rate to fall.

Figure of the estimates of AIDS

    The fact that many countries have undergone this transition does not indicate the success in others. Circumstances in Africa and some Asian countries are vastly different from those European countries when they undergo the transition. Many poor countries are at risk of the demographic trap, which is the negative feedback loop. This occurs when a country undergoes the first stage of the transition with an overstretched ecosystem -- as in Africa. Under such conditions, a rising population can easily lead to famine. The improvement in preventive medicine and public health leads countries into the transition before their fragile economies can feed, house and sustain the consequent increase in numbers. The second stage of the transition, which has a lower birth rate, simply doesn't happen as rapidly as it is needed. In some cases, it doesn't happen at all!

Salt solution is given to babies to avoid dehydration after diarrhoea

It is agreed that there is a vast unmet demand for contraception in developing countries. Although the provision of birth control is not exclusively a medical affair, the cooperation of medicine is vital. Some doctors, such as Dr. Maurice King of the Department of Public Health Medicine in the University of Leeds feel that more radical action may become inevitable.

In 1990, Dr. King set out the health problems of the poor and put them in the context of global ecology. He also wrote of the need for the rich countries to modify their lifestyles, of the importance of devising more equal ways of distributing world resources and of the global initiative that might set these changes in motion.

Source: U.S. Bureau of the Census

World POPClock Projection

Draw your own graph of the population growth here within the site!

    The expectations of people living in rich industrial countries are altogether more demanding than those of the poor. The politician Enoch Powell (British minister of health, 1960-1963), declared that there is virtually no limit to the amount of health care an individual is capable of absorbing. Although this claim is controversial, it is true to say that the effective minimization in the suffering of people was notable. Yet far from growing contented with what they have, many of the citizens of these privileged countries view both present and future with apprehension.

    First comes the matter of cost. For many years, developed countries have been accustomed to a rising expenditure on health. This seemed appropriate at first, but as the proportion of the country's wealth deployed creeps upwards, doubts have begun to appear, especially in the USA where the expenditure on medicine accounts for more than 13% of the GNP (gross nation product). This is relatively the highest of any Western nation. It may be difficult to identify the optimum amount of spending on healthcare, but the Americans sense that benefits are not keeping pace with the outgoings. They are sure that something will have to be done to limit the out flow. Some states are trying out their own schemes.

    The Oregon State Legislature instructed its Health Services Commission to arrange all publicly funded healthcare services in order of priority. They also take account of the views of the public. The commission then worked out the annual cost of providing such healthcare services. Once the annual state Medicaid budget has been worked out, it would be possible to estimate how far the money would go.

    The public views are taken in several forms. Telephone surveys were used. The commission also held public hearings at which special interest groups were able to plead their case. The priority list that finally emerged comprised of just 700 items. In fact, the state's first budget under the new system had 587 items. Item 588, which is not to be funded, was medical and surgical treatment of acne.

    Even though the Oregon experiment may seem a bit cruel, it does provide some pointers for anyone contemplating the future of healthcare financing. Commentators have pointed out that this was simply making explicit a process that will happen sooner or later. In a wholly free market it is rationed by the purchaser's ability to pay for it; in a state-funded system it is rationed by the willingness of the government to pay the bills, and by the waiting lists that form when demand for a particular procedure outstrips supply.The Oregon approach defines the choices that have to be made, and offers a system for making them. If the system does not exist, these decisions will have to be made according to political expediency, and in line with professional interests. The means used in Oregon will surely become a feature of all collectively funded health systems.

    Another feature of the Oregon approach was that the commissioners weighted their decisions according to the quality of the patients' lives after treatment. Although this makes the calculation more onerous, it will soon become a regular part of all calculations of medical costs. Finally, there is public consultation. Though following public opinion in making complex technical decisions maybe foolish, a total neglect of the popular view of what is worth doing is not in any way better. Oregon has pointed the way forward.

    The high cost of scientific medicine is not simply a consequence of people seeking and getting more of the same. Many of the diagnostic and treatment innovations devised by medical researchers depend on a new and expensive gadgetry. An example of this is when bypass surgery first came into practice a few decades ago. Small blood vessels are taken from the leg to fasten a new blood supply to the heart muscle. More recently surgeons have developed a technique called angioplasty, in which using X-ray guidance, a small balloon at the end of a fine tube is threaded through the blood vessels and into the blocked coronary artery. Pumping up the balloon restores the artery to its normal diameter. Small coiled springs can also be placed in the expanded vessel to keep it open. Researchers are developing lasers with which to unblock the coronary artery from inside. So this goes on. With technology, what was once a death sentence can now be replaced. This is true for many other branches of medicine from kidney transplant to artificial hip.

         New drugs are subject to close scrutiny of their safety and effectiveness, but control over new instruments and procedures are less vigourous. A system for getting X-ray pictures of soft as well as bony tissues, called the body scanner, was invented in Britain. However it was in the USA that the instruments began to proliferate. This rapid spread was due to the improved outcome of the patients' treatment. They were glamourous and offered physicians another profitable investigation. Proper technology assessment would prevent such excesses. But when the system is thoroughly applied, it cannot prevent the extra cost arising through those equipments which are truly valuable. It is still hard to see how the growth of the expenditure can be contained with the shortage of banning research and development. In this respect, state-financed healthcare system will have to be in a stronger position. They can simply refuse to pay for a new equipment or procedure available. However private expenditure is more difficult to limit.

   Hope can be seen in the field of genetics and molecular techniques. They suggest that costly procedures such as bypass surgery can be eventually replaced by cheaper molecular-based approaches for preventing disease or dealing with it at an earlier stage of its development. There are some new and improved treatments that have already proved to be money-savers. For example, 60 million dollars were saved every year  by using a new treatment for chronic skin disease psoriasis. This is a healthy return on research investment.