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.
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